Kansas Family Medical Assistance
Manual (KFMAM)
Eligibility Policy - 11/21/2024
01000: Administrative Information -
01100 Health Benefit Programs - Several health benefit programs are provided to low-income Kansans to help cover the cost of health care.
1101 Medicaid - The Medicaid program is a joint federal/state-funded program that covers a majority of low-income persons in the State including children and pregnant women. Policies for family related medical coverage are in this manual while policies for other medical programs are located in the KDHE MKEESM Manual.
1102 Children's Health Insurance Program (CHIP) - The CHIP program is based on a federal block grant program and is intended to serve children under the age of 19 who are uninsured and who are not otherwise eligible for Medicaid.
01120 Basis of Programs and Policies - The Kansas Department of Health and Environment - Division of Health Care Finance (KDHE-DHCF) has the responsibility to develop state plans for furnishing assistance and services to eligible individuals and to determine the general policies relating to the medical assistance programs. The Kansas programs are independent from programs administered in other states unless otherwise stated in this manual. An application for assistance in Kansas shall be treated as a new application.
Therefore, a new determination of eligibility rendered by another state shall not, in and of itself, affect eligibility in Kansas.
Policies set forth in this manual are based upon various federal and state statutes and administrative regulations. The following citations provide an overview of the primary statutory and regulatory references on which the programs are based.
Medicaid
-42 United States Code Annotated (U.S.C.A.), Subsection 1396a et seq.
-42 Code of Federal Regulations (C.F.R.), Parts 430 - 456
-Kansas Statutes Annotated (K.S.A.), 39-708c, 39-209(e)
-Kansas Administrative Regulations (K.A.R.), Chapter 30, Article 6 and Chapter 129, Article 7
CHIP
-Section 2103 of Public Law 105-32
-Kansas Administrative Regulations (K.A.R.), Chapter 30, Article 14
Fair Hearings
-42 Code of Federal Regulations (C.F.R.), Part 205
-Kansas Statutes Annotated (K.S.A.), 75-3306
-Kansas Administrative Regulations (K.A.R.), Chapter 30, Article 7 and Chapter 129, Article 7
Confidentiality Policies
-Kansas Statutes Annotated (K.S.A.), 39-709b
-Kansas Administrative Regulations (K.A.R.), Chapter 30, Articles 2-11
This manual has been developed to implement the policies set forth in the above-mentioned statutes and administrative regulations. Thus, the provisions of the manual are to be followed by program staff when determining eligibility of applicants or recipients for assistance in accordance with K.A.R. Chapter 30, Article 2.
Providing assistance is a continuing and comprehensive process, embracing all parts of the administration of the welfare program. All of the steps or parts of the process are interrelated and must be planned for, and ultimately judged, in terms of the effectiveness of the complete administration.
1131 Volunteers - May be used in related activities such as outreach or assisting applicants in completing the application, other prescreening activities, and securing needed verification. Individuals and organizations who are parties to a strike or lockout and their facilities may not be used in the certification process except as a source of verification for information supplied by the applicant.
1132 Data Collection of Racial/Ethnic Categories - The Case Manager may request applicants to voluntarily identify their racial or ethnic status on the application form and shall inform the applicant(s) that this designation shall not affect their eligibility.
The Case Manager may ask the applicant to identify his racial/ethnic origin during a telephone contact. However, there are certain stipulations that are necessary when the self-identification process is used in either the application process or a telephone contact.
1132.01 - Applicants shall be assured by the Case Manager that information is used for statistical purposes only in determining if the program is administered without discrimination. Racial/ethnic data shall have no effect on an applicant's eligibility to participate and it will not be used for discriminatory purposes.
1132.02 - The applicant shall be advised that the information is used to ensure that benefits are available to all eligible persons regardless of race, color, or national origin.
1132.03 - Applicants shall be advised that the information given will be confidential and, should they decide not to provide this information, such a decision will not have an adverse effect on determining their eligibility.
01200 Rights and Responsibilities -
01210 Availability and Confidentiality of Information -
1210 Rights of Applicant/Recipient -
1210.01 Right to Make Application - An individual shall have the right to make application regardless of any question of eligibility or agency responsibility. The right of an individual to make application may not be abridged.
1210.02 Right to Information - A client has the right to be provided with information concerning the types of assistance, which are provided by the agency. Upon request, the agency shall furnish the client with informational pamphlets and will explain to him/her the categories of assistance for which he/she may be eligible and the eligibility factors for each.
1210.03 Right to a Private Interview - A client has the right to a private interview whenever he/she is discussing his/her individual situation with the agency.
1210.04 Right to Receive a Prompt Decision - A client has the right to have a timely decision rendered on his/her application. See 1405. A recipient has the right to a decision rendered on any other formal request (such as a request for information) within 30 days of its receipt by the agency.
1210.05 Right to Restored Benefits - If the client has been wrongfully delayed, denied, or terminated, he/she is due restored benefits.
1210.06 Right to Correct Amount of Assistance - The client, if eligible, shall be entitled to the correct determination of benefits based upon budgetary standards or allowances in accordance with agency policies.
1210.07 Right to Equal Treatment - All clients have a right to equal treatment in similar circumstances and no person shall be denied benefits or be subject to discrimination on the basis of race, color, or national origin, gender, religion, age, disability, political beliefs, sexual orientation, or marital or family status.
The client has the right to file a discrimination complaint with either the Federal or the State agency.
1210.08 Right to a Fair Hearing - A client has the right to request a fair hearing on any agency decision or lack of action in regard to his application for or receipt of assistance.
1210.09 Right to Withdraw from the Program - An applicant has the right to withdraw his application at any time between the date the application is signed and the date the notice of the agency decision is mailed. A recipient may withdraw from a program at any time.
1210.10 Right to an Individual Determination of Eligibility for Assistance - A client shall be given an opportunity to present his request and to explain his situation.
1210.11 Right to Written Notification of Action - A client has the right to a written notification of agency action concerning his eligibility for assistance.
1211 Responsibilities of Applicant/Recipient -
1211.01 Responsibility to Submit Identifiable Application - The applicant shall submit an application containing a legible name and address (unless homeless), and which has been signed.
1211.02 Responsibility to Supply Information - A client has the responsibility to supply, insofar as able, information essential to the establishment of eligibility.
Information, which is "time-sensitive" and received in the office through a drop box, mail slot or other such manner at the opening of the business day shall be considered as received that business day. This policy does not apply to verification/information that has a time and date stamp, such as e-mails and faxes. Those items are generally considered received the day of the date and time stamp. Information, which is received as a fax or copy, but is required in original form, shall be considered as received when the fax/copy arrives in the office provided the original document arrives in a timely manner as determined at the local level. In general, a fax or copy of a document shall be acceptable without requiring an original (including an application form or monthly report form). However, an original document shall be required for establishing age, identity and citizenship and alienage status, and when determined to be necessary based on prudent person judgment.
1211.03 Responsibility to Provide Verification - The client has primary responsibility for providing verification (certain exceptions to these requirements are specified in the verification section). See 1330.
1211.04 Responsibility to Authorize Release of Information - A client has the responsibility to give written permission for release of information when needed.
1211.05 Responsibility to Report Changes - Persons have the responsibility to report changes in circumstances within 10 calendar days from the date the change is known. See 7120 for specific changes that change reporting persons are required to report.
1211.06 Responsibility to Cooperate - The client shall cooperate with all program requirements and in supplying required information.
1211.07 Responsibility to Provide Social Security Numbers - Each applicant/recipient shall provide his/her Social Security number. See 2031.
1211.08 Responsibility to Meet Needs - A client has the responsibility to meet his/her own needs insofar as he/she are capable.
1212 Responsibilities of the Agency - Upon request, the agency must explain the rights and responsibilities of clients and the following requirements placed on the agency.
1212.01 Periodic Reviews - The agency is required to make periodic reviews of eligibility if the application is approved.
When a formal review is required, the agency shall notify the client of the expiration of the review period and shall send the client a renewal form prior to the last month of the review period.
1212.02 Fraud - The agency is required to investigate and refer for legal action any alleged fraud related to the receipt of assistance.
1212.03 Responsibility to Accept an Identifiable Application - The agency shall accept an application containing a legible name and address (unless homeless) and which has been signed. See 1401.
1212.04 Responsibility to Review Recipients Timely - The agency has the responsibility to process all subsequent applications timely so there will be no break in the benefits the client is eligible to receive.
1212.05 Responsibility to Establish Claims of Overpayment - The agency is responsible for establishing claims for overpayment (either fraud, client, or agency error).
1212.06 Responsibility to Restore Lost Benefits - The agency shall restore benefits to the client if benefits were wrongfully denied, delayed, or terminated.
1212.07 Responsibility for Giving Notice of Action - The agency is responsible for giving adequate and/or timely notice of action when appropriate.
1212.08 Case File Documentation - The agency has the responsibility to ensure that case file documentation supports the decision to provide, deny or change eligibility, benefits, or services.
1212.09 Cost-Effective Service Provision - Services shall be provided in the most cost-effective manner in order to provide the client with the appropriate services within the resources allowed.
1221 Confidentiality of Information Concerning Applicants or Recipients - Information concerning applicants or recipients (present and past) is confidential and may not be disclosed to another DCF employee, the client, or any other nonagency personnel except as set forth in this section.
Information concerning clients or providers who have been referred for investigation is confidential and may not be released unless the Fraud Unit or the prosecuting attorney to whom the case has been referred for legal action authorizes such disclosure.
1222 Disclosure of Confidential Information - The agency may disclose confidential information when the purpose of such disclosure is directly related to: (1) the administration of the KDHE-DHCF program; (2) an investigation, prosecution, or criminal or civil proceeding conducted in connection with the administration of the KDHE-DHCF program or the SSI program; or (3) the administration of any federal or federally assisted program which provides assistance (in cash or in kind) or services directly to individuals on the basis of need. For exceptions see 1225 and 1226.
Throughout this material related to confidentiality of case records, the term KDHE-DHCF and DCF employees includes contracted employees (e.g., contractor employees responsible for CHIP determinations).
1223 Nature of Information to be Safeguarded - The confidential nature of the following information must be safeguarded:
1223.01 - Names and addresses, including lists of applicants or recipients.
1223.02 - Information contained in applications, reports of investigations, reports of medical examinations, correspondence, and other records concerning the condition or circumstances of any person for whom or about whom information is obtained, and including all such information whether or not it is recorded; and
1223.03 - Records of agency evaluations of such information. General information, not identified with particular individuals, such as total expenditures made, number of recipients, and other statistical information and social data contained in general studies, reports, or surveys of welfare problems, does not fall within the class of material to be safeguarded.
1224 Disclosure of Information to Client - Information entered in the case record is to be made available to the client upon request, for inspection at a time mutually agreeable to the agency and the client, except as set forth below.
1224.01 Information Provided by Other Agency Programs - Information provided by other agency programs is not to be made available to the client unless the respective program regulations authorize such disclosure. This includes programs such as Prevention and Protection Services, Rehabilitation Services, Food Assistance, and Cash Assistance that are managed by DCF and Substance Abuse, Mental Health and Developmental Disabilities that are managed by KDADS.
1224.02 Medical and Psychiatric Reports - Medical and psychiatric reports are not to be made available to the client unless signed, written consent is obtained from the medical practitioner who rendered such report.
1224.03 Names and Addresses of Complainants - The names and addresses of complainants are not to be made available to the client.
1224.04 Investigative Reports - Investigative reports concerning welfare fraud or other types of overpayments are not to be made available to the client during the course of the investigation or during the time period in which the case has been referred for legal action unless the Fraud Unit, Legal Division or the prosecuting attorney to whom the case has been referred for legal action authorizes such disclosure.
NOTE: With the exception of 1224.03, all documents and records to be used by the agency at a fair hearing are to be made available, upon request, to the appellant or his representative for inspection and/or copying at a reasonable time mutually agreeable to the agency and the client or his representative prior to the date of the hearing.
1225 Disclosure of Information to Agency Personnel - Information is not to be disclosed to another KDHE-DHCF, DCF, or KDADS employee unless the employee has a need for the information in the performance of his official duties. The client's signature on the application form authorizes the disclosure of information concerning a Caretaker Medical, Extended Medical, TransMed, Child Care, Medicaid, CHIP, and/or Food Assistance client if the purpose of such disclosure is connected with the administration of any of the aforementioned programs, the Child Welfare or Child Support programs (under titles IV-B, IV-D, and XX), or any other federal or federally assisted program which provides assistance, in cash or in kind, or services directly to individuals on the basis of need. (Example: SSI, LIEAP.)
1226 Disclosure of Information to Nonagency Personnel and the Public - Information is not to be disclosed to nonagency personnel such as courts, school boards, legislators, prosecuting attorneys, policemen, FBI agents, doctors, social service agencies, state employment offices, public housing authorities, landlords, creditors, relatives, etc., except as set forth below.
1226.01 Information Available to the Public - Information Available to the Public - Regulations, Plans of Operation, state manuals, and federal procedures, which affect the public, shall be maintained in the office of the KDHE-DHCF for examination by members of the public on regular workdays during the regular office hours.
1226.02 Directly Related to the Administration of KDHE-DHCF Programs - Information may be disclosed to nonagency personnel when the purpose of such disclosure is directly related to the administration of KDHE-DHCF programs or assisting DCF or KDADS in the administration of their programs. The information concerning a cash, medical, childcare, or food stamp client is not to be disclosed without the signed written consent of the client unless the purpose of such disclosure is directly related to one of those programs. Any information disclosed is to be limited to that which is reasonably necessary to accomplish the purpose of such disclosure. Such purposes include establishing eligibility, determining amount of assistance, and providing services to applicants or recipients.
In the course of providing services to clients, disclosure of information should be made to representatives of other welfare agencies or programs only when they can give assurance that:
(1) - the confidential nature of the information will be preserved;
(2) - the information will be used only for the purposes for which it is made available (such purposes should be reasonably related to the purposes of the KDHE-DHCF program and the functioning of the inquiring agencies); and
(3) - the standards of protection established by the agency to which the information is disclosed are equal to those established by KDHE-DHCF itself, both with regard to the use of information by staff and the provision of protective office procedures.
1226.03 Federal or Federally Assisted Programs - Information concerning clients is to be disclosed to federal or federally assisted programs which provide assistance (in cash or in kind) or services directly to individuals on the basis of financial need if the requesting agency certifies in writing that the information so requested is necessary to the administration of its program. Example: SSI.
1226.04 Officials Conducting an Investigation, Prosecution, or Criminal/ Civil Proceeding - Information is to be disclosed to the official conducting an investigation, prosecution or criminal or civil proceeding in connection with the administration of the KDHE-DHCF program if such information is reasonably necessary to the investigation, prosecution or criminal or civil proceeding. This includes welfare fraud investigations and prosecutions. The client's signature on the application/redetermination form authorizes the disclosure of information from the case record necessary to conduct an investigation, prosecution, criminal or civil proceeding related to eligibility for medical assistance.
Information concerning clients is to be disclosed to the official conducting an investigation, prosecution or criminal or civil proceeding in conjunction with the administration of the SSI program if such information is reasonably necessary to the investigation, prosecution, or criminal or civil proceeding.
Information disclosed pursuant to the above paragraphs shall be provided the appropriate official in the following manner:
(1) - The official requesting such information shall be allowed to review pertinent case record material in the agency office during normal working hours.
(2) - Such official, upon request, shall be furnished with copies, or authenticated copies, or originals of pertinent case record materials as necessary at no cost. Prior to the release of an original document, a copy of the document shall be placed in the case record with a notation as to the disposition of the original.
If a question arises as to the pertinency of any requested material, consult the Office of the Medicaid Inspector General.
1226.05 Intention to Commit Crimes - Information concerning the intention of a client to commit a crime and the information necessary to prevent the crime shall be disclosed to the appropriate authorities.
1226.07 Information Not Otherwise Authorized to be Disclosed - Information not otherwise authorized to be disclosed by this provision may only be disclosed if the client has the authority to disclose such information and the agency has a signed, written consent on file authorizing the agency to disclose the information to the specific person requesting such information, excepting that such information may be disclosed without signed, written consent in an emergency situation such as death or other serious crises to an appropriate person if the agency deems such unauthorized disclosure to be in the best interest of the client. If such information is disclosed without signed, written consent, the client shall be notified of such disclosure as soon thereafter as possible.
1227 Subpoenas and Testifying in Court Concerning Information Not Otherwise Authorized to be Disclosed - Since all information relative to a client is by law confidential and since clients are advised that any information they reveal is held confidential, any information received by the Case Manager or other person connected with the agency, is by statute, in the nature of a privileged communication just as is the information received by an attorney or physician from his client, or received by a minister in the performance of his function as a spiritual advisor.
The Legal Division must be notified immediately of a subpoena to produce records or of a court order to testify; such notice should be in writing whenever time permits. A staff member who is subpoenaed or whose records are subpoenaed, unless otherwise instructed by the Legal Division, should make appearance at the time and place stated in the subpoena, and should bring the records subpoenaed with him, if any.
After being sworn in he should make the following statement to the court in response to the first material question:
"I am attending the court's hearing as a result of a subpoena. The law and KDHE-DHCF policy require that I call the court's attention to the laws and regulations limiting use and disclosure of information concerning public assistance. K.S.A. 39-709b limits the use or disclosure of information concerning applicants and recipients of assistance to purposes directly connected with the administration of the assistance program, unless there is written consent given by the consumer. These federal laws and regulations also similarly limit use and disclosure":
1227.01 - Section 1902(a)(7) of the Social Security Act, codified at 42 U.S.C. Sec. 1936a(a)(7), and 42 C.F.R. Sec. 431.300, et seq. (the Medicaid Program);
The witness will submit the above statement in its entirety to the court and a copy to the attorney and will testify further according to the ruling and instructions of the court. Testifying and releasing confidential information when ordered to do so directly by a judge in an in-court setting is not considered unauthorized disclosure of information. See 1229.
1228 Questions Concerning Disclosure of Information - When there is some question as to the disclosure of information to another KDHE-DHCF, DCF, or KDADS employee, the client or other non-agency personnel, the question is to be referred to the legal division for clearance.
1229 Unauthorized Disclosure of Confidential Information - A KDHE-DHCF employee who discloses confidential information concerning an applicant or recipient (present and past) in violation of the provisions set forth in 1220 and subsections shall be subject to appropriate disciplinary action (official reprimand, suspension, demotion, dismissal, etc.).
Further, any individual who discloses confidential information concerning an applicant or recipient (present, past) in violation of the provisions set forth in 1220 and subsections shall be subject to criminal prosecution, and if convicted, may be fined up to $1,000 and/or sentenced to the county jail for a period not to exceed six months.
01300 Prudent Person - Eligibility staff shall use the prudent person concept in administering the Medical Programs. The phrase, "prudent person" applies to the particular situation that indicates further verification of information is needed. It also applies to the reasonableness of judgments made by an individual in a given situation based on that individual's experience and knowledge of the program.
01310 Staff Responsibility - Staff must be prudent when the circumstances of a particular case indicate the need for further clarification. Additional confirmation or verification should be obtained whenever the information provided by the applicant or recipient is incomplete, unclear, or contradictory.
Circumstances that may require a more thorough analysis of a case include:
1310.01 - An individual who appears to be confused.
1310.02 - An individual who has a history of providing conflicting or incomplete information.
1310.03 - Documents (birth certificates, Social Security cards, etc.) that appear to have been altered.
1310.04 - Information obtained from non-medical through KEES according to the following guidelines:
a. Earned income that is currently budgeted on an open or pending case; or was included on a non-active case if the income started within the past three months.
b. Unearned income that is currently budgeted on another case in any status, except for expired time-limited unearned income.
c. Other information currently used for another open or pending case that, if were validated, would result in a different eligibility outcome.
1310.05 - Documents provided by the applicant (pay stubs, employer statement, tax returns, etc.) that appear to be incomplete due to missing required information (i.e., pay dates, frequency, or tax form Schedule 1 or 1040).
01320 Simplified Eligibility - The applicant is the primary source of information used by the agency for purposes of determining eligibility. For some factors of eligibility, additional information will have to be obtained. The agency shall use, to the greatest extent possible, the information on the application/redetermination as provided by the individual applicant/recipient, for purposes of determining eligibility and extent of entitlement.
1320.01 - Carefully review the application for completeness, clarity, consistency, and lack of error or questionable statement.
1320.02 - Consider additional information from agency records.
1320.03 - Advise the applicant/recipient when it is necessary for the agency to go to other sources, and when necessary, obtain his consent on the information release form. If he does not consent to the necessary contacts, it may not be possible to determine that initial or continuing eligibility exists. Each applicant and recipient give consent to a full field investigation when he signs the application/redetermination form, but a signed informational release form may be necessary to obtain the needed information. See 1211.04.
1320.04 - Give the applicant/recipient the opportunity to present additional clarification when information on the form is incomplete, unclear, or inconsistent, or where other circumstances in the particular case indicate to a prudent person that further inquiry needs to be made. Negative action as a result of failure to provide the information can be taken only when written notice was given allowing at least 12 calendar days from the date the notice is initiated to return the information.
1321 Resolving Conflicting Information - When conflicting or contradictory information is discovered, the eligibility staff person shall research the medical case file and other sources, such as interfaces, to determine if a reasonable explanation exists.
If the discrepancy is not resolved, contact with the consumer is required. First, phone contact must be attempted. If the issue remains unresolved a written request for information is issued, as per 1332.01 below. Eligibility cannot be denied or terminated solely based on the discrepant information until the consumer has been given the opportunity to explain the discrepancy. Unless the consumer consents to negative action based upon their request, a written request for information must be issued prior to any negative action.
Staff are responsible for updating the case file (e.g., journal) with information regarding the discrepancy as well as the resolution. If the staff person made a judgement call regarding a specific situation, an explanation of the facts of the case as well as the factors that lead to the decision are also included in the journal. As each situation is unique, the extent and content of the necessary journal entry will depend upon the circumstance of the case.
1330 Verification - A four-tiered approach is used to verify information needed to determine eligibility. Federal law requires that information available through interfaces and other sources are used prior to contacting the consumer. The verification process will proceed in order from Tier 1 through Tier 4 and is not limited only to verification of income. When a Reasonable Compatibility test has been previously run and it has been determined that an administrative error was made or a new self-attestation is received, it is acceptable to return to a prior tier to verify the information (including running a new RC test with the updated information).
The four tiers apply to all family medical assistance programs. See also 1333.04(3) (Earned Income), 6125 (Pre-tax and Federal Deductions), 6122 (Reasonable Compatibility) and 6120 (Budgeting Method). See 2040 for requirements regarding citizenship/identity verification.
1330.01 Tier 1: Payer Interfaces - Reported information is verified through the use of a payer source interface (Federal Hub, Social Security, Unemployment Compensation, KPERS). Since this data comes directly from the source of the reported information, it is considered verified.
Note: If there is a difference between the reported SSA or SSI amount and the amount verified through the Federal HUB, the Social Security interface (EATSS) may be accessed to resolve the discrepancy. If reported SSA or SSI is not showing on the EATSS record, a collateral contact with SSA may be needed.
Reported unearned income not verifiable through a payer source interface shall be verified as indicated in 1330.04(2).
Also included as a payer source for purposes of this section are paystubs, or other comparable documentation voluntarily provided by the employee or employer at the time of application or request for assistance, which are sufficient to determine the countable amount of earned income without request for further verification. To be considered sufficient, the information provided must meet one of the following:
a. All paystubs received in the 30 days immediately preceding the date of application or request for assistance;
b. Paystubs which allow calculation via year-to-date totals of gross earnings received in the 30 days immediately preceding the date of application or request for assistance;
c. A written statement from the employer attesting to the employee’s gross earnings received in the 30 days immediately preceding the date of application or request for assistance, including the date(s) and frequency of payment; or
d. Any other document or documents from either the employee or employer which verifies the total amount of gross earnings received by the employee in the 30 days immediately preceding the date of application or request for assistance.
If the information voluntarily provided is sufficient to verify earned income, no further verification is required. The information voluntarily provided shall be used to determine the amount of earnings. If insufficient to verify the earned income, the information voluntarily provided is not considered a payer source.
Note: If sufficient information as described above is not voluntarily provided at the time of application or request for assistance, eligibility staff shall not request paystubs or additional information as part of the Tier 1 process. Verification shall proceed through the remaining Tiers 2 through 4, in order.
1330.02 Tier 2: Automatic Interfaces - Reported information is verified through the use of a secondary non-payer source interface. Tier 2 interfaces include wage verification from either The Work Number (TALX) or Kansas Department of Labor (KDOL) wages. All resources used to verify citizenship and identity are also included in Tier 2, such as Kansas VRV and KSWebIZ.
The Reasonable Compatibility test is used in Tier 2. See 6122 for Reasonable Compatibility. When income is not determined to be Reasonably Compatible and the Both Below is not applicable, the following Tier 3 sources are used in the order presented and should always be used prior to requesting verification from the applicant.
1330.03 Tier 3: Research - Manual research by the eligibility worker is required. This may include review of the case file, reconciling information received from Tier 2 interfaces, checking other available program information, and making collateral contacts. Any decision to verify reported information at this level must be thoroughly documented.
When an IBU for an applicant/recipient meets the Household RC test for ‘Both Below’ (see 6122.02) and all other factors of eligibility have been satisfied, additional verification is not required. The individual is eligible for Medicaid. It is not appropriate to continue to Tier 3 verification for this applicant or to delay approval of coverage while pending for information for other household members.
Manual research shall progress through the following steps in the order listed:
a. The Work Number (TALX) - When the Work Number (TALX) data is not successful in establishing reasonable compatibility in Tier 2, the income details may be used to verify income reported. Staff will obtain the TALX Monthly Income Amount from the Reasonable Compatibility Test Detail in KEES and use this for the determination. If Work Number (TALX) data is not available, proceed to researching the case file.
b. Case File - The medical case file record shall be searched for hard copy verification of the reported information. This includes the images located in the medical case. The date of wage verification must be within the three months prior to the month of application when processing a new application. When processing a review or case change, the income must be from the three months prior to when the initial RC test was run. If no hard copy information is found in the case file, proceed to the DCF images.
c. Department for Children and Families (DCF) Images - A manual search of the DCF case records shall be completed for usable images to satisfy verification requirements if a consumer was part of a DCF case for a relevant time period. If verification cannot be obtained from DCF images, proceed to collateral contact.
d. Collateral Contact – Collateral contact may be made to verify the reported information, when deemed appropriate. If verification cannot be made via collateral contact, proceed to Tier 4 level verification.
1330.04 Tier 4: Request for Information - If the earnings cannot be verified using the above methods, Tier 4 verification is used, and the information is requested from the consumer. See also 6122 (Reasonable Compatibility) and 6120 (Budgeting Method).
(1) Self-employment Income - Self-employment income must be verified through Tier 3 or Tier 4 as there is not a data-source for this information. It is verified through either the tax return or the KC-5150 Self-Employment worksheet as indicated below.
When the applicant indicates they have filed taxes, a copy of their tax return is required. If it is after the IRS mandated filing deadline (typically April 15th) and the applicant has not filed their tax return, the prior year’s return may be used if they have filed an extension with the IRS. Verification of the extension is not required.
The KC-5150 Self-Employment Worksheet is used to request income and expenses for the 12 months prior to the month of application. This form is generated through KEES by staff and mailed locally. It is used in the following circumstances:
a) It is a new business and a tax return has not yet been filed.
b) It is an existing business, but the applicant has not (or will not) file a tax return.
c) A change in the amount of self-employment income is reported.
d) The tax return is no longer representative of the self-employment income. The reason for the discrepancy must be clearly documented and is only allowed when there is a definitive change in the amount or type of business. When the applicant indicates their tax return is not representative of the existing self-employment income, both the tax return and the KC-5150 Self-Employment Worksheet are required.
(2) Unearned Income - Tier 1 payer interfaces are used to verify SSA income and Unemployment Compensation. Because this information is directly from the source, the amount verified through the interface shall be used regardless of what has been reported by the applicant.
For unearned income types not verifiable through Tier 1, self-attestation is accepted as verification of all unearned income with the exception of the following types which will need to be requested from the consumer as Tier 4 verification:
a) Annuity Income
b) Trust Income
c) Contract Sales
d) Insurance Payments
e) Oil Royalties and Mineral Rights
f) Railroad Retirement
(3) Earned Income – Verification of earned income is required for all individuals. A request for information is sent to the applicant and "the last 30 days of income" is requested as proof. Proof of income is acceptable as long as the date of paystubs or employer statement falls within the three months prior to the month of application. If partial income is received from within this timeframe, it may be budgeted using the Partial Month Budgeting Method, see 6124.
1330.05 Verification of Pre-Tax Income and Federal Deductions - When total reported pre-tax or federal deductions is over $300.00 per month, verification of deductions will be required for them to be used in the income determination. If proof is not received, processing may be completed without them, and the applicant advised by notice that the amount was not used. Eligibility may not be denied due to failure to provide proof of deductions.
Verification of pre-tax income and/or federal deductions will follow the tiered approach of earned income in 1330. Information on hand, such as the case file and the Work Number (TALX) records must be used if available prior to requesting the information from the consumer. Paystubs must be no older than three months prior to the month of application to be used. Collateral contact with the employer may also be used but is not required. If there is no available information on file, the information must be requested from the consumer as noted below:
a) Pre-tax income deductions – Paystubs from the last 30 days or a statement from the employer
b) Federal/IRS deductions – Corresponding tax form or most recent tax return
Note: If based on the consumer’s self-attestation of both wages and deductions, the income will exceed guidelines for all programs, it is not necessary to request proof of the deductions.
1331 Sources of Verification - Once it has been determined that Tier 4: Request for Information is the only method of verification, the following information applies:
1331.01 Documentary Evidence - Documentary evidence consists of a written confirmation of a household's circumstances. Examples are wage stubs, tax returns, and school enrollment records. Acceptable verification shall not be limited to any single type of document and may be obtained through the household or other sources.
1331.02 Collateral Contacts - A collateral contact is a verbal confirmation of a household's circumstances made by a person outside of the household. The collateral contact may be made either by mail or over the telephone. The acceptability of a collateral contact shall not be restricted to a particular individual but may be anyone who can be expected to give an accurate third-party verification of the household's statements. Examples of acceptable collateral contacts are employers, landlords, social service agencies, migrant service agencies, and neighbors of the household.
1331.03 Self Attestation - Self-attestation or Client Statement is sufficient as verification for several elements. Although it is acceptable to verify those items with a Tier 1 or Tier 2 interface, the individual is never asked to provide verification. An exception exists if the information reported is discrepant or inconsistent. The test for this varies dependent upon the context of the information in question as well as the other information in the case.
A declaration of income is used when determining Reasonable Compatibility of Income as defined in 6122. Declaration of income may be taken from the application form, written correspondence, or through verbal contact with the applicant.
A request for coverage is denied when the self-declared income exceeds the income guidelines for the program and does not require verification. When this occurs, the notice of action shall contain detailed information of what income was used.
1332 Responsibility for Obtaining Verification - The household has the primary responsibility for providing verification to support its statements and to resolve any questionable information. Information may be provided in writing or verbally. Any reasonable evidence provided by the household shall be accepted. Staff shall be primarily concerned with how adequately the verification proves the statements on the application. If it would be difficult or impossible for the household to obtain documentary evidence in a timely manner, staff shall offer assistance to the household in obtaining documentary evidence in a phone call and/or send a notice that includes the offer of assistance to all households. The household shall not be held responsible when a person outside of the household fails to cooperate with a request for verification.
As it relates to income, where all attempts to verify the income have been unsuccessful because the person or organization providing the income has failed to cooperate with the household and the Agency, and all other sources of verification are unavailable, the Eligibility staff shall determine an amount to be used based on the best available information.
1332.01 Discrepancies - Where information from another source contradicts statements made by the household; the household shall be afforded a reasonable opportunity to resolve the discrepancy prior to an eligibility determination. Information needed to resolve the discrepancy shall be requested from the household, however, if the household fails to provide the necessary information, staff may elect to verify the information directly. Households are to be given 12 days to provide necessary verification. If the client does not or refuses to provide adequate verification to resolve the discrepancy, the case may then be closed, or the application denied if that is the appropriate case action.
1333 Mandatory Verification - Eligibility staff shall verify the following information prior to approval for initial applicants, when processing a review, or a reported change.
1333.01 SSN - An applicant is required to supply their Social Security Number or verification of application for the required SSN prior to approval of coverage unless the individual claims good cause or qualifies for exemption. See 2033. The reported SSN is then verified using either the Federal HUB or SVES in Tier 1, or through EATSS-SSA in Tier 2. Verification of the SSN does not include a copy of the paper SSN card. Verification of the SSN is a once-in-a-lifetime requirement. For persons without an SSN, they must apply for an SSN and provide proof of application. The requirement to supply and verify an SSN does not apply to non-citizens who would only qualify for a non-work SSN, such as refugees, asylees, and special immigrants.
When an applicant fails to provide an SSN or proof of application for an SSN, he or she may qualify for a Good Cause exception, see 2033.
1333.02 Citizenship and Identity - Persons applying for medical assistance attesting to be a citizen must have citizenship and identity verified as described in 2045. Unless otherwise exempt, this applies to all applicants. This is a once-in-a-lifetime requirement. Information is not requested from the client once citizenship and identity are verified.
This requirement does not apply to the following individuals:
- Current or former SSI recipients
- Current or former Medicare beneficiaries
- Current or former recipients of Social Security Disability benefits
- Children currently in foster care or recipients of foster care maintenance. (See 2045 to address verification once released from DCF custody)
- Children who are recipients of adoption support payments
- Children born on or after July 1, 2006 to a Medicaid recipient as outlined in 2320.
Tier 1 verification includes the Federal HUB.
Tier 2 verification includes Web-IZ. When the Web-IZ is from Vital Statistics, it can be used as proof of both citizenship and identity. Otherwise, it is only proof of identity.
Note: For verification of citizenship and identity, it is acceptable to access the file in Tier 3 to determine if documentation has previously been provided before accessing the Tier 2 sources. Both Tier 2 and Tier 3 must be followed before proceeding to Tier 4.
Tier 3 and 4 verification can include birth certificates and other paper documents. See KDHE Eligibility Policy-Appendix Item A-12 and 2045.
1333.03 Non-Citizenship Status - Qualified non-citizenship status must be verified for persons applying for coverage. Verification is not required for SOBRA but may be necessary to establish the individual is not a qualified non-citizen. Verification is accomplished through the Department of Homeland Security and additional verification steps may be necessary. The SAVE process is used to obtain the information. Verification is not requested for non-applicants.
Tier 1 verification includes the Non-Citizen VLP through the Federal HUB, including subsequent SAVE processes.
Tier 2 includes the manual SAVE process.
Tier 3 includes information available in the case file.
A Reasonable Opportunity period may be granted for persons who fall to Tier 4. The Reasonable Opportunity period is granted only if the individual reports a non-citizenship status that would qualify him/her for medical assistance. See 2047.01.
1333.04 Income - Unless otherwise indicated, income must be verified. See also 6122 (Reasonable Compatibility) and 6120 (Budgeting Method).
(1) Self-employment Income - Self-employment income must be verified. It is verified through either the tax return or the KC5150 Self-Employment worksheet as indicated below.
When the applicant indicates they have filed taxes, a copy of their tax return is required. If it is after April 15th and the applicant has not filed their tax return, the prior year's return may be used if they have filed an extension with the IRS. Verification of the extension is not required.
The KC5150 Self-Employment Worksheet is used to request income and expenses for the 12 months prior to the month of application. This form is generated off-system by staff and mailed locally. It is used in the following circumstances:
a) It is a new business and a tax return has not yet been filed
b) It is an existing business, but the applicant has not (or will not) file a tax return.
c) A change in the amount of self-employment income is reported.
d) The tax return is no longer representative of the self-employment income. The reason for the discrepancy must be clearly documented and is only allowed when there is a definitive change in the amount or type of business. When the applicant indicates their tax return is not representative of the existing self-employment income, both the tax return and the KC5150 Self-Employment Worksheet are required.
(2) Unearned Income - Tier One payer interfaces are used to verify SSA income and Unemployment Compensation. Because this information is directly from the source, the amount verified through the interface shall be used regardless of what has been reported by the applicant.
For unearned income types not verifiable through Tier One, self-attestation is accepted as verification of all unearned income with the exception of the following types:
a) Annuity Income
b) Trust Income
c) Contract Sales
d) Insurance Payments
e) Oil Royalties and Mineral Rights
f) Railroad Retirement
(3) Earned Income – Verification of earned income is required for all individuals. When earnings have not been reported, they are verified against available earned income data sources, as outlined below in section (4).
The Reasonable Compatibility test is used in Tier Two. See 6122 for Reasonable Compatibility. When income is not determined to be Reasonably Compatible and the Both Below is not applicable, the following Tier Three sources are used in the order presented and should always be used prior to requesting verification from the applicant.
a.) Work Number (TALX) - When the Work Number/TALX data is not successful in establishing reasonable compatibility, the income details may be used to verify income reported. Staff will obtain the TALX Monthly Income Amount from the Reasonable Compatibility Test Detail in KEES and use this for the determination. Note: Usually TALX will provide a prospective amount for this purpose, but in some instances, it will use an actual amount (i.e. a sum vs. an average) depending on information provided by the employer, see note on 6122.
b) Hard-copy Wage Verifications - Staff shall review the medical case file to determine if hard copy verification has been submitted by the applicant. This could be in the form of paystubs or a statement from an employer. The date of wage verification must be within the three months prior to the month of application when processing a new application. When processing a review or case change, the income must be from the three months prior to when the initial RC test was run.
c) DCF Images - A manual search of the DCF case records shall be completed for usable images to satisfy verification requirements if a consumer was part of a DCF case for a relevant time period. If verification cannot be obtained from DCF images, proceed to collateral contact.
d) Collateral Contact – Collateral contact shall be made to verify the reported information, when deemed appropriate. If verification cannot be made via collateral contact, proceed to Tier 4 level verification.
e) Request Information - If the earnings cannot be verified using the above methods, Tier 4 verification is used. A request for information is sent to the applicant and "the last 30 days of income" is requested as proof.
(4) Zero Earnings – It is necessary to verify the absence of earnings for all individuals. This is applicable to all individuals who do not report earnings, report non-wage income only, such as self-employment or unearned income, or fail to answer questions about their income. Earned income sources are also checked for children. Even though most children will not have earnings found, this income test is a necessary element of the Both Below Reasonable Compatibility test as outlined in 6122. System interfaces will be checked to verify that no earnings exist. The Reasonable Compatibility Test will be used in Tier 2 to verify that no earnings exist. If no earnings are found in both TALX and KDOL (BASI) the zero earnings are considered verified.
When data sources are not able to confirm the absence of earnings, it is necessary to evaluate if proof of the income is going to be required prior to proceeding. When an applicant’s IBU meets the Household RC test for Both Below and there is no other information, other than income, that is still pending, the applicant is eligible and should be approved for Medicaid without further verifying the IBU income. When Both Below is not applicable, continue to Tier 3 sources and use in the order presented:
a) The Work Number/TALX – When Work Number/TALX returns wage information, staff will evaluate the check dates returned on the Reasonable Compatibility Detail page. If the latest check date is older than 30 days, this is indicative that there has been a change in income. The lack of reported earnings is accepted and considered verified. If the latest TALX check date is within the last 30 days, staff will obtain the TALX Monthly Income Amount from the Reasonable Compatibility Test Detail in KEES and use this for the determination. It is considered current and countable income. If the consumer later contests the use of this income, proof of the end of the income would be required and the eligibility will be redetermined if appropriate.
b) Case File – When KDOL (BASI) wages are returned for the quarter prior to the current quarter, staff shall research the case file for information that may indicate the recent loss of employment. If an explanation is found that substantiates the report of no income, then further research into the KDOL (BASI) wages are not required. The zero earnings are considered verified.
(5) Proof of End of Income
Self-attestation of the end or absence of income is acceptable, with the exception of the following:
a) Individual is a CHIP premium-payer and reports a reduction/elimination of income.
b) TransMed (TMD) or Extended Medical (EXT) recipient reports a reduction/elimination of income.
c) The consumer contests to the use of income found in a data source.
1333.05 Medical Expenses - The amount of any medical expenses used to meet a spenddown must be verified in order to allow it against the spenddown. Failure to verify expenses doesn't disqualify the individual, as eligibility is determined without allowing the expense. Medical expenses for Spenddown submitted through Provider Billing protocols in the MMIS are considered verified if proper procedures are followed.
1334 Information Known to the Agency - The agency is required to act on information when it becomes known. The phrase’ Known to the Agency’ establishes the point in time that the agency is made aware of information in order to act upon such information for purposes of eligibility determination/redetermination. These policies do not negate the consumer’s responsibility to report information (see 7100), but are meant to provide required parameters when reacting to new information.
See 7140 for processing changes.
1334.01 Definition of Agency - Agency means the single state Medicaid/CHIP agency as well as any contractors or other state agency units authorized to determine eligibility for medical assistance or provide direct support of the medical assistance eligibility determination process. Currently, this means the KanCare Clearinghouse, KDHE Outstationed Workers, KDHE Central Office – Eligibility Unit and DCF PPS workers who make medical determinations. It also includes automated systems that determine medical assistance eligibility to the extent the information is used in the medical assistance determination.
1334.02 Date Information is Known - The date information is considered known to the Agency establishes the date by which information must be acted upon. This date is determined by the source/channel of the information:
1. Information reported directly to the Agency by a consumer or third party, by any channel, is considered known on the date it is reported. Examples:
• The date of a phone call from the consumer reporting a change in income
• The date of receipt of written correspondence
• The date a Nursing Home reports a change in living arrangement
• The date a new application is received, whether for a new household or an existing household reporting a change or a new member
2. Information that originally becomes known to another state agency but is communicated to the Agency as part of an approved business process is considered known on the date the information was reported to the Agency. Examples:
• The date DCF creates a task notifying KDHE of a new medical condition that a mutual client originally reported to DCF
• The date DCF creates a task notifying KDHE of a change in health insurance premium amount
3. Information obtained through an interface used by the medical assistance programs which populates information directly into KEES is considered known on the date the information is added to KEES. Examples:
• The date a TBQ adds new Medicare entitlement to the Medicare Information page
• The date an SDX task is created from a Social Security interface telling KDHE that SSI has ended.
4. Information originally obtained through another program through any channel that was not directly reported to the Agency, is considered known based on the type of information received.
a. Information received through a shared data field in KEES and is immediately used for case processing through an automated process is known on the date the information is added to KEES. Example:
• The date DCF updates an address in KEES for a mutual client.
b. Information received through a shared data field in KEES is considered known on the earlier of the date the information is used for processing or the date it is viewed by a person considered part of the Agency. Example:
• DCF updates health insurance premium at the end of the day. The review batch runs that evening and uses the health insurance premium in the new determination. DCF notifies KDHE of the change the following day. The information is considered known on the date of the review batch, because the information was used to redetermine medical benefits.
c. Information available only through a non-shared data field in KEES is considered known on the date it is viewed by someone considered part of the Agency. Example:
• The date a KDHE staff person views a DCF income record
01340 Discrepancies and Questionable Information - A discrepancy and/or Questionable Information is identified when information from one source contradicts statements from another source. To be considered questionable, the information on the application must be inconsistent with other information on the application or previous applications or inconsistent with information received by the agency. When determining if information is questionable, the decision shall be based on each household's individual circumstances. Also see 1310 and 1320.
Eligibility staff shall verify factors of eligibility prior to approval only if they are questionable and affect the household's eligibility.
01350 Documentation - Case files must contain documentation to support the determination to approve or deny program benefits. Documentation means that a written statement regarding the type of verification and a summary of the information obtained has been entered in the case record. Such statements must be in sufficient detail so that a reviewer would be able to determine the reasonableness of the determination. The results of the Reasonable Compatibility Test along with the Verification Tier used shall be included in the documentation. For example, when income is verified by the presentation of pay stubs, the gross amount of income on each pay stub, and the frequency of receipt of income are included on a copy of the pay stub in the case record or are recorded by the Eligibility Staff elsewhere.
Where verification was required to resolve questionable information, the Eligibility Staff shall document why the information was considered questionable and how the questionable information was resolved. The Eligibility Staff shall also document why any alternate sources of verification were needed and, if a collateral contact was rejected, the case file shall contain documentation of why the collateral contact was rejected and an alternate chosen.
01400 Application Process/General Information -
1401 General Information - An application is defined as a request for medical assistance. Individuals can apply for medical assistance in one of the following ways:
a) Online application submitted through the Self Service Portal (SSP)
b) Paper application form submitted by mail or in person at the KanCare Clearinghouse
c) Telephone application
d) Transfer of a request from the Federally Facilitated Marketplace (FFM)
e) Request by phone for individuals in households with already open medical programs (see 1402)
Based on the provisions of 3000, an application shall include all required persons. Required persons are as follows:
- The individual,
- The individual's spouse,
- The individual's children under age 21 living with them,
- The individual's partner who lives with them when they have mutual children,
- Any other individual who is on the individual's tax return (whether or not they live with them), and
- Anyone else under age 21 who lives with the individual and they care for.
The application, together with the agency records (if any), the necessary forms (budgets, notices of action, narratives, etc.), and any required verification must substantiate eligibility or ineligibility.
At the time of application processing, each month shall be viewed separately in determining eligibility or ineligibility. For example, if an application is filed in July but processed in August, ineligibility in August shall not affect the eligibility determination for the month of July.
1402 How to Apply - Each household has the right to file an application on the same day it contacts with the agency. Application forms can be requested from any local DCF office, KanCare Clearinghouse, or KDHE-DHCF Outstationed Worker. All requests for medical assistance must be made on KDHE-DHCF forms as follows:
KC1100 - Medical Assistance Application for Families with Children
KC1500 - Medical Assistance for the Elderly and Persons with Disabilities
Such applications are to be submitted to the KanCare Clearinghouse; a central operation established to determine eligibility for all medical programs. A contractor is currently used to manage the Clearinghouse. Applications provided to the local DCF office are immediately transferred to the Clearinghouse for processing.
Note: Online applications are received through the KDHE-DHCF Customer Self-Service Portal (CSSP).
When an application is requested in person, the household shall be encouraged to file the application that same day. When an application is requested over the telephone or in writing, it shall be mailed the same day, when possible, or the following business day.
NOTE: If the applicant household is homeless and they have no street address to list, the application shall be so noted and accepted by the agency.
Neither an application form nor signature is required to add additional household members to an existing medical program unless the medical program has remained active beyond the review period due to timeliness factors. If the medical program has remained active past the required review period, only submittal of a signed application form will constitute a request for coverage.
1403 Application Date - The date of receipt by the agency of a validly signed application is considered the application date for establishing initial eligibility and for processing purposes.
1403.01 Paper Applications - The date a paper application is received by the agency shall be considered the application date. All signed paper applications shall be date-stamped the date physically received at the KanCare Clearinghouse, an Outstation Worker site, or other location designated by the agency.
A paper application that is received through the mail or physically delivered to agency personnel on agency premises shall be considered received that date. An application that is received through a drop box, mail slot or other such manner at the opening of the business day shall be considered received that day, even if the application was deposited prior to that date.
An application received by the agency via email or fax is deemed an original application and is considered received on the date on the time stamp if received by 5:00 pm on a business day. If the application is received after 5:00 pm on a business day or on the weekend or a holiday, the application date is the next following business day.
When an applicant files an application form that is not intended for the medical coverage requested, additional information may be requested, but the application date is the date the application is received by the agency. Completion of the appropriate form is not required to establish the application date for the coverage requested.
Note: Date-stamping of a paper application by someone other than agency or agency contracted personnel does not constitute a date of receipt for application purposes.
1403.02 Online Applications - The date an electronically signed online application is received by the agency shall be considered the application date if received by 5:00PM on a business day. If the application is received after 5:00PM on a business day or on the weekend or holiday, the application date is the following business day.
1403.03 Other Electronic Applications - The application date for other electronic applications received by the agency is described below. MIPPA and FFM applications both have two (2) application dates – one for processing purposes and one for eligibility purposes.
FFM Applications - The date the electronic data file is received by the agency from the federally facilitated health insurance marketplace exchange is the application date for processing purposes and establishes the 45-day processing timeline. The date the original health insurance exchange subsidy application was filed with the Federally Facilitated Marketplace (FFM) is considered the date of request for medical assistance and therefore is the start date for eligibility purposes.
MIPPA Applications - The date the electronic data file is received by the agency from social security is the application date for processing purposes and establishes the 45-day processing timeline. The date the original Low-Income Subsidy (LIS) application was filed with Social Security is considered the date of request for MSP and therefore is the start date for eligibility purposes. Note: Since the original LIS applications on which these applications are based do not include a request for prior medical assistance, there is no MSP eligibility for months prior to the request month of these applications.
PE Application – The date the PE Application is received by the agency shall be considered the application date.
1403.04 Telephonic Applications - The application date for a telephonic application is the date the applicant answers all the questions and telephonically signs the application by certifying, under penalty of perjury, that they understand the questions and statements read to them and his/her answers are correct and complete to the best of their knowledge.
1403.05 Unsigned Applications - An unsigned application received by the agency is not considered an application for processing purposes. All unsigned applications shall be promptly returned to the applicant for signature.
The entire application shall be returned to allow the applicant to review his/her answers prior to certifying under penalty of perjury that all answers are correct and complete to the best of their knowledge. A cover letter must be attached to the returned application explaining the need to sign the application and return to the agency for processing.
If the originally unsigned application is returned with a valid signature, the application date for processing purposes is the date the returned application is received by the agency if received on a business day. If the application is received on the weekend or a holiday, the application date is the next following business day.
Note: An online application may not be submitted without a signature. Therefore, there should never be an online application received without a signature. The signature may be invalid (see subsection 1403.06), but there should always be a signature.
1403.06 Invalid Signature - An application received by the agency with an invalid signature is considered an application for processing purposes. An invalid signature is one in which the person who signed the application has no authority to act on behalf of the applicant (see 2110 and subsections).
When an application with an invalid signature has been received by the agency, the application (or a copy of the application for online applications) shall be returned to the applicant with instructions to either verify the authority of the person who signed the application or to sign the application in their own name (if legally competent to do so).
If verification of authority to sign the application or if the application with the applicant’s own signature is timely received by the agency, the application date for this application is determined by the following:
a. If verification is provided documenting that the person who signed the application was authorized to apply on behalf of the applicant at the time the application was received by the agency, the application date is the date the application was originally received by the agency.
Note: If the application indicates that the person signing the application has authority to apply on behalf of the applicant (such as a person holding a Durable Power of Attorney or is a guardian or conservator of the applicant), but no verification has been provided at the time of application, the process described in this section does not apply. In that instance, the signature is initially considered valid, and the agency shall send a request for information to provide verification of the authority.
b. If the applicant responds by formally designating the person who signed the application as his/her medical representative according to 2010.02, the application date is the date documentation of the medical representative authorization is received by the agency if received on a business day. If the medical representative authorization is received on the weekend or a holiday, the application date is the next following business day.
c. If the application is returned with the applicant’s own signature, and the applicant is legally competent to apply on their own behalf, the application date is the date the returned application with the valid signature is received by the agency if received on a business day. If the returned application is received on the weekend or a holiday, the application date is the next following business day.
This provision also applies where someone other than the applicant, who is verified to act on behalf of the applicant according to 2010 and subsections, signs and timely returns the application to the agency.
If verification of authority to sign the application or if the application with the applicant’s own signature (or of someone who can act on behalf of the applicant) is not timely received, the application shall be denied due to an invalid signature based on the date the application was originally received.
1403.07 No Program Request - The application date for an application received with no program request is the date the application is physically received at the KanCare Clearinghouse, an Outstation Worker site, or other location designated by the agency. Immediate contact with the applicant shall be made to determine which programs are being requested.
The program(s) requested shall be registered using the date of receipt of the application as the application date for those programs only. Any subsequent request for other programs by the applicant shall be registered with an application date based on the date of request for the additional program(s).
Note: An online application may not be submitted without a program request. Therefore, there should never be an online application received without a program request.
1404 Who May File - An application for assistance shall be made by the individual in need or by another person able to act in the individual's behalf. See 2010. If the applicant or his representative signs by mark, the names and addresses of two witnesses are required. Obtaining the signatures of all persons in the family group who are requesting assistance and able to act in their own behalf per 2010 is encouraged, but cannot be required.
1404.01 Filing on Behalf of a Deceased Person - An application shall be made on behalf of a deceased person in the month of death or within the three following months by the following individuals:
• A parent of the decedent where the decedent is a minor;
• The surviving spouse of the decedent;
• An adult child of the decedent;
• An adult in the decedent’s tax household; or
• An executor or administrator (including temporary) of the decedent’s estate.
1404.02 Filing for Institutionalized Individuals - When possible, all necessary information and signed forms will be obtained by institutional personnel. Parents, spouses, guardians/conservators and others who may apply on behalf of the individual per 2010 must always be given the opportunity to apply on behalf of an institutionalized person not able to act in his own behalf. If institutionalized personnel are unable to obtain the required forms from the patient or any of the above individuals, the administrator of a licensed facility may apply on behalf of the patient. General hospitals are not regarded as a licensed facility for this purpose.
Complete applications will be forwarded to the DCF office or KanCare Clearinghouse for processing.
All information pertinent to eligibility and known by institutional staff will be communicated to the local office. When the institution acts as an employer to the patient, institutional personnel will be responsible for reporting all earnings to the local DCF office.
Generally the local DCF office where the institution is located will process new applications. However, when appropriate, the local office or KanCare Clearinghouse shall determine whether the individual is currently included on an open medical case before processing. If the individual is included on a currently open case, the application shall be denied. The referral and a copy of the application shall be sent to the current county or CH where the appropriate case action will be taken to certify eligibility to the institution. (See 7300.)
For individuals who currently have an unmet spenddown, the institution should be notified as no FFP can be claimed until the spenddown is met. Medical expenses incurred at the institution shall be considered toward the unmet spenddown and eligibility certified when the spenddown is met.
1404.03 Filing for Individuals through the Federal Health Insurance Marketplace - Individuals may apply for medical assistance through the Federal Health Insurance Marketplace. The Marketplace application allows any adult member of the tax household to apply for any and all other members of the tax household. Should the agency receive an application via file transfer from the Marketplace, it shall be accepted and processed even if the individual filing the application does not meet the requirements of 2110 and subsections. The application shall be registered following standard procedures, establishing the correct individual as the primary applicant.
1405 Withdrawing the Application - The household may voluntarily withdraw its application at any time. The agency shall document in the case file the reason for withdrawal, if any was stated by the household, and that contact was made with the household to confirm the withdrawal. The household shall be advised of its right to reapply at any time subsequent to withdrawal.
1406 Universal Access - An individual or family can apply for medical assistance at either a DCF office or the KanCare Clearinghouse. DCF accepts these applications but does not process them. Applications are gathered and transferred to the KanCare Clearinghouse several times a week. The DCF Service Center where the application is filed shall inform the consumer about the transfer to the KanCare Clearinghouse. The application date is not based on when the application is received by DCF. See 1403.
1407 Time in Which Application is to be Processed and Case Disposition - All applications shall be approved or denied on a timely basis except when a determination of eligibility cannot be made within the required period due to the failure of the applicant or collateral to provide required information. Written notice must be given to the applicant by the end of the required period giving the reason(s) for the delay. The approval of an application from an alien who is otherwise eligible may not be delayed beyond the timely processing time frame due solely to the fact that no USCIS response to a request for verification of immigration status has been received.
Timely action is defined as follows:
1407.02 All Other Medical Applications - Within 45 days of the agency's receipt of a signed application. For management purposes the agency shall strive to process applications within 30 days.
1408 Presumptive Eligibility - (PE) is a process that allows qualified hospitals and qualified entities to determine if an individual is eligible for temporary short-term medical assistance. The PE determination is a simplified process based on information provided by the applicant. Standard application procedures, such as obtaining hard copy documentation, are not required for a presumptive decision. PE grants immediate temporary medical coverage to persons pending their formal application for KanCare. The PE Program is designed for uninsured low-income persons in the following populations:
• Children
• Pregnant Women
January 1, 2014 the Affordable Care Act (ACA) implemented the options for hospitals to self-elect to determine presumptive eligibility and expanded the group for which hospitals could determine. This group includes adults in one of the following groups:
• Low-income Caretakers
• Former Foster Care
• Breast or Cervical Cancer recipients diagnosed through Early Detection Works (EDW)
Presumptive Eligibility for Pregnant Women only covers outpatient ambulatory services related to pregnancy. All other presumptive eligibility groups receive full Medicaid coverage.
Qualified Entities (QEs) eligible to complete PE determinations for the above adult population include all clinics and hospitals. The Presumptive Eligibility determination is final. The applicant household does not have appeal rights regarding the outcome of their presumptive determination.
1408.01 Qualified Hospitals and Qualified Entities - KDHE-DHCF is responsible for certifying all entities qualified to make Presumptive Eligibility decisions. Certain Medicaid enrolled hospitals and Safety Net Clinics have been designated Qualified Entities allowed to make presumptive eligibility decisions.
All entities must complete training and receive certification by KDHE-DHCF prior to making any determinations.
Presumptive Eligibility is determined through the Presumptive Eligibility (PE) Portal. Once entity staff have received training and are deemed certified, they will gain access to the PE Portal.
Qualified Hospital
A qualified hospital is a hospital that
(1) Participates as a Kansas Medicaid provider, notifies KDHE of its election to make presumptive eligibility determinations, and agrees to make presumptive eligibility determinations consistent with Kansas policies and procedures,
(2) Assists individuals in completing and submitting the full KanCare application and understanding any documentation requirements, and
(3) Has not been disqualified by KDHE.
Qualified Entity
A qualified entity is
(1) Healthcare providers, community-based organizations, schools, head start programs authorized by the state to screen for Medicaid and CHIP eligibility and immediately enroll adults, children, and pregnant women who appear to be eligible,
(2) Assists individuals in completing and submitting the full KanCare application and understanding any documentation requirements,
(3) Has not been disqualified by KDHE.
1408.02 Qualified Hospital/Entity Responsibilities - Staff at each Qualified Entity/Hospital are responsible for identifying adults, children, and pregnant women who could benefit from the Presumptive Eligibility Program.
Staff will make presumptive decisions as well as inform families of the program. They will also assist families who wish to apply for coverage with completing the KanCare application. This assistance shall include completion and submission of the application, assistance in obtaining supporting documentation, and follow-up with the family to provide support through the application process.
The following processes must be completed by the Qualified Entity when making a presumptive determination:
1. Complete the training program provided by DHCF upon becoming a QE and ensure that new employees are trained.
2. Attend recertification training if mandated by DHCF.
3. Follow all policies and procedures outlined in the PE Resource Manual and training material.
4. Offer PE to uninsured persons accessing services.
5. Confirm through the KMMS that prospective PE recipients are not currently covered.
6. Determine PE based on the information in the PE Portal in accordance with the instructions in the PE Resource Manual and training material and instructions in the PE Portal itself.
7. Assist families in the completion of a KanCare application, which includes providing assistance in obtaining required verifications for application processing; families denied PE should still receive assistance in completion of the KanCare application.
8. Provide the parent/guardian or adult applicant the signed Approval or Denial determination letter Notice and a copy of their application following their PE determination.
9. Provide each parent/guardian or adult applicant determined eligible verification of the coverage start date. This eligibility verification is in the form of an approval letter which includes the approved individual’s name, date of birth, and the date coverage begins. The approval letter is proof of coverage until the individual has their medical card and uses this as proof of eligibility, or the provider must verify eligibility through the KMMS.
10. Inform families in writing and verbally of the reason the applicant(s) was found ineligible for PE coverage and assists the household in completing the formal application process even though the applicant was not presumptively eligible. A presumptive determination is based on household statements and a simplified process which may not have the same outcome as the formal eligibility determination completed by KDHE-DHCF.
11. Educate the parent/guardian or adult that future communication on their KanCare application will be from the KanCare Clearinghouse and provide the parent/guardian or adult with the KanCare Clearinghouse contact information.
12. Provide the family with comprehensive assistance to ensure a successful completion of their KanCare application. This may include contacts with families prior to appointments to encourage them to bring necessary documentation at the time of service, follow-up contacts with the family, assistance in obtaining documentation, and agreeing to photocopy and fax documents to the KanCare Clearinghouse.
13. Meet the performance standards outlined below:
a. 95% of PE determinations are completed accurately,
b. 90% of individuals are offered help from PE staff to complete the full Medicaid application.
c. 85% of approved PE applicants ultimately achieve eligibility through the KanCare process.
14. Maintain a record of PE determinations for 5 years.
15. Maintain client confidentiality.
1408.03 KanCare Clearinghouse Responsibilities - Staff at the KanCare Clearinghouse record the results of each Presumptive Eligibility determination and enter presumptive coverage in the Kansas Eligibility Enforcement System (KEES).
Presumptive Eligibility is determined in the Presumptive Eligibility Portal (PE Portal) and then entered into KEES. The following individual medical subtypes are recorded in KEES:
• PEN/CH – Medicaid Child
• PET/CH – CHIP Child
• PEN/PW – Pregnant Women
• PEN/CT – Adult Caretaker
• PEN/BC – Breast or Cervical Cancer
• PEN/AO – Foster Care Aged Out
The KanCare Clearinghouse is responsible for completing the determination of ongoing eligibility under MAGI programs.
1408.04 Applicant Responsibilities in the Presumptive Eligibility Process - The adult applicant household member is responsible for providing the Qualified Entity staff with household information to be used in making the Presumptive Eligibility determination, see 1211.02. Information provided to each entity for purposes of making a presumptive eligibility determination must be true and correct, see 8410.
1408.05 Period of Presumptive Eligibility - Presumptive Eligibility coverage begins on the date the determination is completed. The approval letter provided to the family by the Qualified Entity shall reflect this date as when the applicant’s coverage begins. Coverage is not provided for days prior to the date on the presumptive eligibility approval letter. The family must complete the KanCare application (and request assistance with unpaid medical bills, if applicable) in order to be determined for potential eligibility for the time prior to the period of presumptive coverage.
Presumptive Eligibility coverage ends the month following the presumptive eligibility determination if a KanCare application is not received.
If the application is received during the presumptive eligibility period, an applicant may continue to receive presumptive coverage until the formal application is processed and a determination of the applicant’s formal eligibility is made.
Children and Adults may only be provided with one Presumptive Eligibility coverage period within a twelve-month period. The applicant must self-declare any prior Presumptive Eligibility coverage to the entity at the time of application. Entities shall check their records to verify Presumptive Eligibility has not been received at their facility. The twelve-month period begins with the month the child or adult is determined eligible for presumptive coverage. For example, Billy is approved for presumptive eligibility on July 10th, 2007. July is the first month of the twelve-month period. Billy cannot receive additional presumptive coverage until July 1, 2008.
Pregnant Women may only be provided one Presumptive Eligibility coverage period per pregnancy.
Presumptive eligibility coverage periods have no impact on continuous eligibility provisions. Continuous eligibility is not applicable until the formal application is processed, see 2310.
The household does not have a right to continuation of benefits upon pending an appeal of the termination of presumptive benefits because the receipt of these benefits is time-limited.
1409 Signature Requirement - As noted in 1403, an application or review form must be signed to be considered a valid request for assistance. The signature must be both valid (see 1403.06) and acceptable. An acceptable signature is one which meets the following requirements.
1409.01 Paper Applications and Review Forms - Any mark or sign made by the person signing the application with the intent to represent the identity of that person is acceptable. This includes handwritten (wet), typed (mechanical), stamped, and scanned signatures. A handwritten signature does not have to be legible to be acceptable. If the person is marking the application with an “X” (or other symbol) because they are unable to sign their name due to illiteracy or disability, the signature of two (2) witnesses to validate the identity of the person making the mark is required.
A signature provided in the wrong place in most instances shall not disqualify the application as long as the signature is both valid and acceptable. This applies to signatures provided on either the signature page or the medical representative authorization page of the application.
Note: While it is not required that the signature be on the correct signature line, it does need to indicate an agreement/authorization of the items preceding the signature section on the signature page, i.e., the rights and responsibilities section of the application or review form.
1409.02 Online Applications - In general the applicant (or applicant’s representative authorized to act on behalf of the applicant) should type his/her full name on the application, which constitutes a valid and acceptable signature. However, when less than the applicant’s (or authorized representative’s) full name appears, the following provisions apply.
1. Acceptable – Using the prudent person concept described in 1300, if the signature submitted on the application provides enough evidence to reasonably identify the signer as the applicant (or authorized representative), the signature is considered acceptable. Examples of acceptable signatures include (but are not limited to) the use of initials, nicknames, or partial names associated with that person instead of his/her legal name, if as long as the identity of the signer can reasonably be discerned from the signature.
2. Not Acceptable – If the signature provided on the application does not provide enough evidence to reasonably identify the signer as the applicant (or authorized representative), the signature is considered unacceptable. Examples of unacceptable signatures include (but are not limited to) partial names or nicknames not normally associated with the person’s formal name, an indecipherable combination of letters and/or numbers, or a name totally disassociated from the applicant.
When the signature has been determined to be unacceptable, an attempt to contact the applicant should be made to confirm the identity of the person who signed the application. If it is confirmed that the applicant (or authorized representative) signed the application, the signature shall be considered acceptable.
1409.03 Telephonic Applications - A person applying telephonically shall be required to verbally certify, under penalty of perjury, that they understand the questions and statements read to them, and that the answers are correct and complete to the best of their knowledge. To complete the telephonic signature, the applicant will be required to state their full legal name. That statement will be recorded and attached to the case as a permanent record.
Based on this process, the verbal signature shall always be deemed to be acceptable. However, if it is later verified that the person who provided the verbal signature was not the applicant (or authorized representative), the signature is considered to be a forgery, and thus an invalid signature (see 1403.06).
1409.04 Unacceptable Application - If the application does not contain an acceptable signature, follow the process described in 1403.06 for invalid signatures.
Note: While the applicant (or authorized representative) is directed to both sign and date the application, failure to date the application (or provide an incorrect date) does not invalid the signature or the application. As long as an acceptable signature has been provided, the signature requirement has been met. See also 1409.
01410 Disposition of Applications - The purpose of this section is to provide instructions regarding the procedures that follow the determination of eligibility or ineligibility for assistance. Eligibility/ineligibility is certified using KEES procedures. A copy of the Notice of Action is to be sent to medical providers to certify eligibility/ineligibility on medical cases when required.
One of the following case actions must occur within the established time period outlined in 1407.
1410.01 Approval - A notice of approval shall be sent for all programs determined eligible.
(1) Approved - The application will be approved for medical, if automatically eligible, or if determined eligible with respect to all factors including financial.
(2) - Approved - Suspended - If the applicant is eligible with respect to all factors other than financial but there is a spenddown (see 6500), the application will be approved in a spenddown status if there appears to be a likelihood that the spenddown will be met within the 6 month eligibility base period using evidence provided by the client and known to the agency. This is an administrative procedure to meet the application disposition time requirements and to preserve the original application date. However, there is no eligibility until the spenddown is met. See 1412 concerning suspension. The individual will however be enrolled with a KanCare managed care organization (MCO). They will be eligible for any value-added services the MCO provides. A medical card will be issued by the MCO, and claims billed will be applied to the spenddown.
For all individuals enrolled in KanCare, the MCO, will issue a medical ID card. For non-KanCare recipients, medical cards are issued by the fiscal agent.
1410.02 Denial - A denial shall be processed to assure that the applicant is provided with his/her denial notice in a timely manner. A notice of denial shall be sent at the time of denial, clearly explaining the reason for the denial.
(1) - Found Ineligible - A denied application may be reinstated without a new application at any time within the original 45-day processing timeline. In no case does the denial of the application abridge that individual's right to reapply at any time.
(2) - Failure to Provide Required Information/Cooperation - An application shall be denied after a period of 12 days from the date of a written request for information, but no later than 45 -days from the date of application when the applicant has failed to provide required information or cooperate with eligibility requirements. The applicant must be informed in writing of the 12-day standard and the date by which the verification /cooperation must be received.
If the information is subsequently received or the household cooperates within the 45-day application processing time period, the application shall be reactivated and, if eligible, benefits prorated from the date of application. If the information/ cooperation is not received within the above time frames, then the client must re-apply.
(3) - Spenddown - When a spenddown is established for a minor who would otherwise be eligible for CHIP coverage, eligibility staff must ascertain the likelihood that the spenddown will be met. In order to make this determination and prevent delaying CHIP approval, contact with the applicant must be made as quickly as possible. The applicant must be informed of the spenddown amount and given a 12- day notice to respond to the likelihood that the spenddown will be met within the 6-month eligibility base period. If the applicant fails to respond or it does not appear that the spenddown will be met, the application will be denied (or case closed for failure to meet the spenddown) and CHIP coverage will be authorized. In spenddown cases where there is no possibility of CHIP eligibility, the spenddown is established, and the case remains open throughout the base period. At the end of the base period, staff determines if there is a need for further spenddown coverage.
(4) - Another Agency Assumes Responsibility - The agency may dispose of the application if another agency assumes complete responsibility for meeting the applicant's need.
(5) - Cannot be Located - The agency may dispose of the application if the applicant has moved and cannot be located. The agency shall not send a notice of decision.
1410.03 Pending - If a decision cannot be made on an application within the applicable timely processing period because of agency delay, the application shall not be denied. Eligibility staff shall notify the applicant(s) that the application is still pending, and what action must be taken to complete the application process and what date the action must be taken by, or the request will be denied.
1411 Provisions Specific to Medical Eligibility - Suspension of medical benefits does not shorten an established medical eligibility base period and a new application is not required to reinstate assistance within the period. Regardless of the procedure used, medical eligibility shall not be suspended without meeting notice requirements related to adverse action. Benefits shall not be suspended for more than 6 months except in rare cases where there is clear documentation that circumstances have changed so that medical eligibility can reasonably be expected within the next 6 month period. If the case is not to be closed, medical eligibility on a medical only case will be suspended.
1412 Termination of Assistance - Case closures will always be effective the last day of a given month. To protect credibility with medical providers, the termination date may not be changed after issuance of a medical card. However, the date of death will be used for a deceased individual since there are no eligible services after that date.
1413 Reinstatement of Assistance - Medical assistance can be reinstated in the month following the month of closure or suspension if the reason for the closure has been cured by the end of the month following the month of the closure/suspension and all other eligibility requirements are met. The exception to this is if medical assistance was discontinued due to whereabouts unknown (see 7230). If the individual was discontinued due to whereabouts unknown and confirms their whereabouts prior to the end of their review period, coverage shall be reinstated back to the date of termination, unless the consumer reports a change in circumstances that will impact eligibility. If this information becomes known, the agency will be required to act on the information. See 1334.
A new application is not required for reinstatement purposes unless the current review period has expired. However, if the review form is returned within the three month reconsideration period (see 7431), the form can be used to redetermine eligibility.
01420 Written Notice of Case Action - An applicant or recipient of assistance shall be notified promptly of the action taken on his case. The recipient of assistance shall also be notified of other changes such as an increase or decrease in the spenddown, cost share, suspension, or reinstatement after suspension.
1421 Notice of Action - Shall be sent promptly to the applicant or recipient with a copy of any manually prepared notices filed in the case record. Specialized notice forms are required for all cases involving a spenddown, and for all cases in which the medical program will assume at least partial payment for care situations.
Notices shall indicate clearly the action taken, the effective date, and such other information as the situation may require. For all medical approvals, notices must include the beginning date of the review period. If an application is denied, the applicant shall be informed of the basis for this action. A similar procedure shall be followed for all other changes.
1422 Timely and Adequate Notice - The agency shall give timely and adequate notice of agency actions to terminate, suspend, or reduce assistance except as provided for in 1422.01 regarding dispensing with timely notice and in 1425 regarding negative actions resulting from information obtained through federal match data. See 7420 for further information on notice provisions for reviews.
1422.01 Adequate Notice - Adequate means a written notice that includes a statement of what action the agency is taking, the reasons for the intended agency action, the specific manual references supporting such action, an explanation of the individual's right to request a fair hearing, and the circumstances under which assistance may be continued if a fair hearing request is made. All notices must be adequate.
1422.02 Timely Notice - Timely means that the notice is mailed at least 10 clear days before the effective date of action. Neither the effective date of action nor the mailing date shall be considered in determining this 10-day period. For closures, the consumer must receive the notice prior to the last day of eligibility. For increases in premium, the consumer must receive the notice prior to the 1st of the month for which the change is effective. The Processing Deadlines Code Card Chart on the KEES Repository shall be used to identify the last day in which action can be taken in order for timely notice to be provided for the various scenarios.
An increase in an unmet spenddown does not require timely notice; however, a change which results in the spenddown changing from met to unmet does require timely notice. When a spenddown for a base period changes from met to unmet, the consumer is notified both by the KanCare Clearinghouse and by MMIS. The MMIS notification must be received before the first day they return to having an unmet spenddown.
1423 Adequate Notice Only - When only adequate notice is required, such notice may be received by the household at the time reduced benefits are received or if benefits are terminated, at the time benefits would have been received if they had not been terminated. The agency is not required to send timely notice but must send adequate notice no later than the date of action when:
1423.01 - The agency denies an application for assistance. However, denials resulting from information obtained through federal match data shall be subject to the provisions of 1425.
1423.02 - The agency has factual information confirming the death of a client or of the payee when there is no relative available to serve as new payee.
1423.03 - The agency receives a clear written statement signed by a client indicating that he no longer wishes assistance, or that gives information which requires termination or reduction of assistance, and the client has indicated, in writing, that he understands that this must be the consequence of supplying such information.
1423.04 - The client has been admitted to an institution and further medical assistance will not be provided to that individual.
1423.05 - The client has been placed in a Medicaid approved institution for long term care or begins HCBS and will receive Medicaid payment for the cost of care.
1423.06 - The client's whereabouts are unknown and agency mail directed to him has been returned by the post office indicating no known forwarding address.
1423.07 - A client has been accepted for assistance in a new jurisdiction and that fact has been established by the jurisdiction previously providing assistance.
1423.08 - A child is removed from the home as a result of a judicial determination, or voluntarily placed in foster care by his legal guardian.
1423.09 - Assistance is approved and negative case action such as a closure is incorporated into the initial notice of action to the client. However, negative action resulting from information obtained through federal match data shall be subject to the provisions of 1425.
NOTE: Timely and adequate notice must be given for any termination in benefits resulting from information obtained by the consumer or other sources.
1423.10 - A client is disqualified for fraud through a court of appropriate jurisdiction.
1423.11 - A premium requirement is established or increased for a CHIP case per 2440.
1423.12 - The agency receives a request to end coverage on the basis of the cost of the CHIP premium obligation.
1424 Automatic Benefit Adjustments for Classes of Clients - When changes in either state or federal law require automatic adjustment for classes of clients, timely notice of such adjustments shall be given which shall be adequate if it includes a statement of the intended action, the reasons for such intended action, a statement of the specific change in the law requiring such action, and a statement of the circumstances under which a hearing may be obtained and assistance continued.
1425 Notice of Actions Resulting from Federal Match Data - Based on the provisions of the Computer Matching and Privacy Protection Act, no immediate action to suspend, terminate, reduce, or deny assistance in the medical program may be taken as a result of information obtained through federal match data which has not been determined to be accurate and reliable by the federal agency producing the data. When the federal information has not been determined to be accurate and reliable, the individual must be given 30 days from the date the notice of action is received to verify or contest the match data. This means that such notice must be sent at least 35 days prior to the effective date of action for recipients or the date the application is to be processed for applicants.
Federal matches currently affected by these provisions include the PARIS, SIEVS (IRS and BEER data) match and VA match. It does not include BENDEX, SDX, SAVE information from INS, and third- party queries obtained through SSA as all of these data exchanges are either considered to be accurate and reliable or involve a computer match process between state and federal records. It also does not include Employment Security matches as this is not a direct federal-state match.
1501 Request for a Hearing - A request for a fair hearing is defined as a clear expression, oral or written, to appeal a decision or final action of any agency or employee of the KDHE-DHCF. The Office of Administrative Hearings in the Department of Administration administers the agency's fair hearing program pursuant to the Kansas Administrative Procedure Act (K.S.A. 77-501 et seq.).
The request may be made orally (either in person or by telephone), in writing (either in person or by mail), by fax, or by email.
The rights, responsibilities, and procedures for fair hearings for other interested persons are similar to those applicants/recipients as explained in this section except that hearings for other interested persons shall be held in Topeka.
The following persons may request a fair hearing:
1501.01 - Any person who is an applicant, recipient, or is authorized to represent the applicant/recipient may request a fair hearing for the individual. This includes the applicant/recipient’s attorney, or an individual appointed as a Medical Representative. Form KC6100 Medical Representative Authorization Form or medical representative section on the application form is required to authorize a representative as stated above. This authorization must be signed prior to the date the request for fair hearing is filed.
In addition, the applicant/recipient can provide a written authorization allowing an attorney, or other individual, to request a fair hearing on his/her behalf. For deceased individuals, only persons specifically authorized by a court or appropriate jurisdiction may request a fair hearing or represent the decedent in a fair hearing action.
1502 Time Period for Requesting a Hearing - The date of request shall be the date the agency received the request. The date of request for oral requests is the day the person requests a fair hearing in person or by telephone. The date of receipt of a fair hearing request submitted after business hours by telephone, fax, or email shall be the next business day.
1502.01 - Unless preempted by federal law, a request for a fair hearing shall be in writing and received by the agency within 33 days from the date the notice of action is mailed. When a request for a fair hearing is received prior to the effective date of action as prescribed in 1503, assistance may be continued.
Such request may relate to an applicant's request for assistance, which is denied, or is not acted upon with reasonable promptness, and to any recipient who is aggrieved by any agency action resulting in suspension, discontinuance, or termination of assistance.
1503 Continuation of Benefits - - If a written or oral request for a fair hearing is received on a Medicaid only program (excludes CHIP) prior to the effective date of action, the notice of adverse action is mailed, and the review period has not expired, assistance shall not be suspended, discontinued, or terminated until a decision is rendered after a hearing, unless:
1503.01 - A determination is made at the hearing by the hearing officer that the sole issue is one of state or federal law or regulation or change in state or federal law and not one of incorrect application of a policy (when appropriate KanCare Clearinghouse staff should raise this issue in the hearing in order for the referee to render a decision).
1503.02 - A change (except the matter under appeal) affecting the recipient's assistance occurs while the fair hearing decision is pending and the recipient fails to request a hearing after notice of the change.
1503.03 - The request for a fair hearing concerns a discontinued program or service.
1503.04 - The review period expires. The household may reapply and may be determined eligible for a new review period with assistance as determined by the agency.
1503.05 - A mass change affecting the household's eligibility or level of coverage or share of cost occurs while the hearing decision is pending.
Assistance shall also be continued at its prior level if the client or agency submits a timely request for review by the State Appeals Committee. See 1507.
NOTE: In any case where action was taken without timely notice, if the recipient requests a hearing within 10 days of the mailing of the notice of action, and the agency determines that the action resulted from other than the application of state or federal law or policy or a change in state or federal law, assistance shall be reinstated and continued until a decision is rendered in the matter as set forth above.
The agency shall promptly inform the household in writing if assistance is reduced or terminated pending the hearing decision. See 1505.05.
1504 Client's Rights Related to a Fair Hearing - The client or the client's representative shall have adequate opportunity to:
1504.01 - Submit a request for a fair hearing (including a request to expedite as described in 1505.06), which may be on the Request for Administrative Hearing form, regarding any agency action. However, a hearing need not be granted if the request concerns only the validity of federal or state law or regulation. In addition, a hearing need not be granted when either state or federal law requires automatic adjustments for classes of recipients unless the reason for an individual appeal is incorrect computation. See 1503.01.
1504.02 - Examine the contents of his case file and all documents and records to be used by the agency at the hearing at a reasonable time before the date of the hearing as well as during the hearing. See 1224 and subsections regarding confidential case file information.
1504.03 - At his option, present his case himself, or with the aid of an authorized representative, and bring witnesses.
1504.04 - Establish all pertinent facts and circumstances and advance any pertinent arguments without undue interference.
1504.05 - Question or refute any testimony or evidence, including opportunity to confront and cross-examine adverse witnesses.
1504.06 - Submit evidence to establish all pertinent facts and circumstances in the case.
1505 Responsibilities of the KanCare Clearinghouse - Every applicant/recipient shall be informed in writing at the time of application and at the time of any subsequent action affecting medical assistance of the right to a fair hearing, the method of obtaining such hearing, and that representation may be by an authorized representative such as legal counsel, relative, friend, or other spokesperson. In addition, the applicant/recipient shall be informed of the circumstances under which eligibility may be continued or reinstated during the appeal as well as an explanation that an appeal decision for one household member may result in a change in eligibility for other household members. Information printed on the application/redetermination form and notices of action will provide this information.
Agency hearing procedures shall be uniform, clearly written, and available to any interested party. At a minimum, the procedures shall include time limits for filing requests for appeals, advance notice requirements, hearing timeliness standards, and the rights and responsibilities of persons requesting a hearing. The Office of Administrative Hearings (OAH) has created a Q&A document describing the Medicaid fair hearing process. That document (OAH Frequently Asked Questions) can be found in the Miscellaneous Section of the Appendix.
1505.01 Standard Procedures - The procedures set forth below shall be followed whenever a client makes an inquiry concerning a fair hearing, asks for fair hearing forms, or files a request for a fair hearing.
(1) The eligibility staff or supervisor should find out why the client is questioning the agency action.
(2) If the client is only disagreeing with a federal or state law or policy, the reason for such policy should be discussed with the client.
(3) If a client appears to be questioning the application of a federal or state law or policy to his individual situation (incorrect eligibility determination or use of incorrect facts), an administrative review shall be conducted to determine if the agency action was correct. Upon reconsideration, the agency may amend or change its decision at any time before or during the hearing. The hearing shall not be delayed or canceled because of this preliminary review.
If a satisfactory adjustment is reached prior to the hearing, the agency shall submit a written report to the hearing officer but the appeal shall remain pending until the client submits a signed written statement withdrawing the request for a fair hearing.
(4) If the client is questioning the decision regarding disability and the decision was made related to an SSI or SSA application for benefits, the client is to be referred to the SSA office to file an appeal. See MKEESM 2636.
(5) If the client is questioning the decision regarding disability and the decision was made by Disability Determination Services (DDS) based on an KDHE request via the DD-1104 and DD-1105, the appeal will be processed through DDS as specified in MKEESM 1614.6(1).
(6) When a household member or representative makes an oral request for a fair hearing to the KanCare Clearinghouse or to the Office of Administrative Hearings by telephone or in person, the agency shall document the request by using the Request for Administrative Hearing form. The date of the request shall be the date the oral communication was made to the agency and that date shall appear on the form. Lack of signature by the household member on the form used to document an oral request shall not invalidate the request.
1505.02 Agency Contact - Once a fair hearing has been received, the KanCare Clearinghouse shall attempt to contact the client, or the client’s representative, by telephone to explain the agency action and the effective date of the action taken.
(1) Unable to Contact - The KanCare Clearinghouse shall make at least two (2) attempts to contact the client by telephone to explain the agency action taken on the case. All unsuccessful attempts to contact the client shall be thoroughly documented in the case file. If the agency is unable to contact the client by telephone to discuss the agency action, the KanCare Clearinghouse shall complete an Agency Summary as described in 1505.04.
(2) Contact Completed - If the KanCare Clearinghouse is able to contact the client by telephone to explain the agency action and the client is satisfied with the agency explanation, the client should be asked if he/she is willing to withdraw the fair hearing request. Whether or not the client is willing to voluntarily withdraw the fair hearing request will determine the next action taken by the agency.
(a) Client Agrees to Withdraw - If the client agrees to withdraw the fair hearing request, the KanCare Clearinghouse shall complete a Motion to Dismiss based on the client’s decision to withdraw the fair hearing request. There is no need to complete an Agency Summary at this point. See. 1505.03.
(b) Client Does Not Withdraw- If the client does not agree to withdraw the fair hearing request and states an intent to continue the appeal, the KanCare Clearinghouse shall complete an Agency summary as described in 1505.04. See also 1505.06 concerning dismissal of fair hearing.
1505.03 Withdrawal of Request - The client may withdraw the request for fair hearing at any stage of the appeal process, up to and including the day of the fair hearing. The request must be in writing and signed by the client or the client’s representative. A special form, Notice of Withdrawal of Appeal, is available for this purpose. The agency may offer this form to the client for completion, but any writing evidencing the intent to withdraw shall be accepted.
The request may be submitted to either the KanCare Clearinghouse or directly to the Office of Administrative Hearings (OAH). The request may be delivered by mail, fax, or in person. The appeal process will continue until the written withdrawal request has been formally received by OAH.
1505.04 Completion of Summary - Within 15 days after the appellant has filed a request for a fair hearing, the KanCare Clearinghouse shall furnish the appellant and the Office of Administrative Hearings (OAH) with a summary. One copy of the summary shall be sent electronically to OAH. Another copy shall be mailed to the appellant or representative. The summary shall include the following information:
(1) Name and address of the appellant;
(2) A summary statement concerning why the appellant is filing a request for a fair hearing;
(3) A brief chronological summary of the agency action which led to the appeal and the agency's action after receiving the request for fair hearing;
(4) A statement of the basis for the agency's decision;
(5) A citation of the applicable policies relied upon by the agency;
(6) A copy of the notice which notified the appellant of the decision in question;
(7) Applicable correspondence; and
(8) The name and title of the person or persons who will represent the agency at the hearing.
When the request for a fair hearing involves a Disability Determination Services (DDS) disability determination, the process described in MKEESM 1614.6(1)(c) shall be followed.
If, through an agency contact as discussed in 1505.02, the appellant has withdrawn the appeal, see 1505.03, completion of the summary is not necessary. The Request for Administrative Hearing form should then be submitted, along with the Notice of Withdrawal of Appeal, to OAH within 7 days of the date of the request for a fair hearing.
1505.05 Informing the Client of Termination of Assistance - The KanCare Clearinghouse shall promptly inform the client in writing if assistance is to be terminated pending the fair hearing decision. See 1503 concerning continuation of assistance.
1505.06 Expedited Fair Hearing - A request to expedite the fair hearing process may be granted for an appellant who demonstrates an urgent medical need. The request may be made either at the time the fair hearing is filed or any time thereafter up to the actual date of the scheduled hearing. If granted, the hearing will be scheduled as soon as possible. If the expedited request is denied, the hearing process will proceed on a normal schedule.
The following additional provisions apply:
(1) Request - As indicated above, a request to expedite the fair hearing process may be made at the time of the request for fair hearing or at any time prior to the scheduled hearing. If the expedited request is received after the original fair hearing is filed, it is important to note that this is not a separate hearing request, but rather simply a request to expedite the process for the previously filed hearing request. Therefore, to avoid duplicating appeals, whenever an expedited request is received, staff should ascertain whether or not there is already an existing active appeal.
(2) Documentation - An expedited request cannot be granted without documentation supporting a claim of urgent medical need. The documentation must be provided at the time of the expedited request. The supporting documentation should be based on medical records and/or the written opinion of a medical professional familiar with the appellant’s condition and circumstances. A simple statement of medical need is not sufficient proof of an urgent medical need, nor are self-serving statements provided by the appellant or by family and friends lacking medical credentials.
Note: Refusal or failure to supply supporting documentation with the expedited processing request will result in an automatic denial of the request.
(3) Evaluation - The documentation provided shall be reviewed by KDHE-DHCF clinical staff to determine if the appellant has an urgent medical need which necessitates the need to expedite the fair hearing. An urgent medical need means that the appellant’s life, health, or ability to attain, maintain, or regain maximum function is in jeopardy if the hearing is not expedited.
As indicated above, the determination will be based on the documentation (i.e.: medical records and/or medical professional statement) provided at the time of the expedited request. That determination is then forwarded to the Fair Hearings Manager.
Please note that this evaluation is not the same as a disability determination for eligibility purposes. The purpose of the review is to determine if an urgent medical need exists which warrants expediting the fair hearing process. The review is not intended to determine if the appellant meets the disability criteria for disability-related medical assistance programs.
(4) Decision- Based on the evaluation completed by the clinical team reported to the Fair Hearings Manager, the expedited request shall be either denied or approved.
(a) Denied - If the expedited request is approved, the Fair Hearings Manager will contact the Office of Administrative Hearings to schedule the hearing as expeditiously as possible, but no later than 7 working days after the date the expedited request is received. The KanCare Clearinghouse shall also complete the Appeal Summary and forward to the Office of Administrative Hearings as expeditiously as possible, but no later than 15 days from the date the fair hearing request is received ,see 1505.04.
1505.07 Federally Facilitated Exchange (FFE) Fair Hearing - An applicant may appeal a decision made by the Federally Facilitated Exchange (FFE) concerning his/her application for coverage and/or eligibility for the subsidy through the Health Insurance Marketplace. That appeal request will be sent to the Marketplace Appeals Center for adjudication. During the appeal process the Marketplace Appeals Center may determine that the appellant is potentially eligible for Medicaid or CHIP coverage.
In that instance, the Marketplace Appeals Center will submit an electronic appeal package to the agency containing consumer account information. The package of information will include not only information provided directly by the applicant when he/she completed the Health Insurance Marketplace application, but also data obtained from the result of any verifications performed by the Federally Facilitated Exchange (FFE). Also included in the package is the appeal request submitted by the appellant. This information shall be used by the KanCare Clearinghouse to review the individual’s eligibility for medical assistance.
Note: the agency should only receive an appeal package for individuals who have already applied for and been denied Medicaid and/or CHIP coverage by the KanCare Clearinghouse.
Upon receipt of the appeal package, the KanCare Clearinghouse shall conduct an administrative review of the case based on the information provided and redetermine eligibility for Medicaid and/or CHIP. If the applicant is determined eligible based on the review, coverage shall be promptly approved with notification provided to the applicant. If the KanCare Clearinghouse determines that the applicant is not eligible, the application shall remain denied. The applicant shall be notified of the decision with the right to appeal. Whatever decision is made, the KanCare Clearinghouse shall also notify the FFE of the outcome of the redetermination.
1505.08 Dismissal of Fair Hearings - By Kansas statute, the agency has no jurisdiction to determine the facial validity of a state or federal statute. Nor does an administrative law judge from the Office of Administrative Hearings have jurisdiction to determine the facial validity of an agency rule and regulation. So, clients have no right to a fair hearing if they simply disagree with a regulation that results in a loss of eligibility. However, clients may have a hearing if they believe that the agency incorrectly applied such regulation to the client's individual situation (use of incorrect facts). The issue is whether the client is only challenging the validity of the regulation or really presenting a factual dispute. If there is no dispute between the client and the agency as to the facts involved, the client's request for a fair hearing in most instances will be dismissed by the hearing officer before the hearing.
As such, if the client is only disagreeing with a federal or state law or regulation (whether a current regulation or one that is changing) and, after following the procedures set forth in 1505.01, wishes to file a request for a fair hearing (or fails to withdraw a request previously filed), the agency should complete a Motion to Dismiss form. The form is to be submitted to the Office of Administrative Hearings within 10 days of the request for a hearing. A copy of the appropriate Notice of Action and the Request for Administrative Hearing form should be attached to the motion. Do not submit an appeal summary unless the motion is denied. KDHE-DHCF must mail a copy of the Motion to Dismiss to the appellant. Staff should complete the Certificate of Service and sign it. Write the actual mailing date on the certificate, as well as the appellant's name and address. On the Motion to Dismiss, the line "Such action is based on" should reflect the appropriate law or regulation. (Contact Eligibility Policy as needed for this information.) For dismissal requests regarding major program changes or cutbacks, specific citations will be provided from the Eligibility Policy Section.
Fair hearings shall also be dismissed if the request is not received within the time periods specified in 1502, or the household or its representative fails, without good cause, to appear at the scheduled hearing, or is received from an individual who is not authorized to represent the applicant/recipient in a fair hearing as indicated in 1501.01.
Assistance shall continue as noted in 1503 until a decision is rendered concerning the dismissal. If the dismissal request is approved, assistance shall be terminated unless the appellant requests State Appeals Committee review within the 15 days allowed. If the dismissal request is denied, assistance must continue until the presiding officer issues an initial order affirming the agency action, unless there is a State Appeals Committee review request.
1506 Place and Conduct of Fair Hearings - Fair hearings for applicants or recipients shall be held in the Social and Rehabilitation Services' administrative area in which the applicant or recipient resides unless another site has been designated by the hearing officer. At least 10 days prior to the hearing, advance written notice shall be mailed to all parties involved to permit adequate preparation of the case.
The hearing officer may conduct the fair hearing or any prehearing by telephone or other electronic means if each participant in the hearing or prehearing has an opportunity to participate in the entire proceeding while the proceeding is taking place. A party may be granted a face-to-face hearing or prehearing if good cause can be shown that a fair and impartial hearing or prehearing could not be conducted by telephone or other electronic means.
At a hearing, the hearing officer shall regulate the course of the proceedings. To the extent necessary for full disclosure of all relevant facts and issues, the hearing officer shall provide all parties the opportunity to respond, present evidence and argument, conduct cross-examination and submit rebuttal evidence, except as restricted by a limited grant of intervention or by a prehearing order.
The hearing officer may, and when required by statute shall, give nonparties an opportunity to present oral or written statements. If the hearing officer proposes to consider a statement by a nonparty, the hearing officer shall give all parties an opportunity to challenge or rebut it and, on motion of any party, the hearing officer shall require the statement to be given under oath or affirmation.
A hearing officer need not be bound by technical rules of evidence but shall give the parties reasonable opportunity to be heard and to present evidence. Evidence need not be excluded solely because it is hearsay.
All testimony of parties and witnesses shall be made under oath or affirmation. Statements of nonparties may be received as evidence.
Any part of the evidence may be received in written form if doing so will expedite the hearing without substantial prejudice to the interests of any party. Documentary evidence may be received in the form of a copy or excerpt. Upon request, parties shall be given an opportunity to compare the copy with the original if available.
The hearing officer may not communicate, directly or indirectly, regarding any issue in the proceeding while the proceeding is pending, with any party or participant, with any person who has a direct or indirect interest in the outcome of the proceeding or with any person who presided at a previous stage of the proceeding, without notice and opportunity for all parties to participate in the communication.
1507 Fair Hearing Decision and Request for Review - A fair hearing decision shall be rendered by the hearing officer no later than 90 days after receipt of the request on a Request for Administrative Hearing form or similar document and the decision shall be sent to the client and the KanCare Clearinghouse.
The client/respondent shall be informed of his right to have the State Appeals Committee review the decision of the hearing officer and also his right to petition to the District Court. A request to the State Appeals Committee must be made within 18 days of the date of the fair hearing decision. The client/respondent may also have the right to request a re-hearing in order to submit additional information or evidence. This request must also be made within 18 days of the date of the fair hearing decision.
Assistance shall be continued at its prior level if the client or the agency requests a review by the State Appeals Committee. Assistance shall continue until a decision is rendered by the State Appeals Committee.
The decision of the Appeals Committee is final and binding upon the client and the agency on the date of the decision. This is true even if one of the parties should appeal the matter to the District Court. Assistance shall not continue at its prior level following the decision of the State Appeals Committee unless there is a court order to the contrary.
1508 Agency Actions Following Fair Hearing Decisions - The decision of the hearing officer shall be implemented immediately upon receipt (including decisions related to disability) if the decision is favorable to the client and the agency does not intend to request a review by the State Appeals Committee. A report of such action shall be submitted to the Administrative Hearings Section. If the agency requests such a review, the decision shall not be implemented until a final decision by the State Appeals Committee has been rendered. Also, if the decision is unfavorable to the client, the decision shall not be implemented until the 18th day following the date of the mailing of the initial decision to allow the client the opportunity to request a review by the State Appeals Committee. If a request is made within the 18-day period, the decision shall not be implemented.
1508.01 Retroactive Payments - When the hearing decision is favorable to the client, or when the agency decides in favor of the client prior to the hearing, the agency shall promptly make corrective coverage.
1508.02 Recovery of Overpayments - When the hearing decision upholds agency action, any overpayment made during the fair hearing process is subject to recovery, except in situations where the action being appealed is the application of a CSS penalty.
1521 Complaint Procedures - A complaint is a verbal or written grievance concerning an agency action or program policy. Any person who is an applicant, recipient, or is authorized to represent the applicant/recipient per 2010.01, 2010.02, 2010.04, 2011, and 2011.01 may file a complaint with the agency.
1521.01 Complaints Received in the KanCare Clearinghouse - Upon receipt of a complaint, the KanCare Clearinghouse shall:
(1) - Review the situation and determine if corrective action is indicated. The determination should be made by the Eligibility Supervisor or Program Administrator after consulting with the Eligibility Specialist.
(2) - Explain the action or policy to the complainant in writing or verbally. If corrective action is necessary, it should be initiated immediately. If corrective action is not indicated, inform the complainant of his right to request a fair hearing and the request procedure.
1521.02 Complaints Received in KDHE-DHCF Administration - Complaints received in KDHE-DHCF Administration will be referred to Eligibility Policy Section for a response. If the response requires KanCare Clearinghouse input, a telephone call or e-mail message outlining the nature of the complaint will be made to the Eligibility Program Administrator or their designee. This person will review the case and determine the appropriateness of the agency's action. If the agency is in error, the Eligibility Program Administrator or their designee will mandate that corrective action be initiated immediately.
Once the determination is completed, the Eligibility Program Administrator or designee will telephone or e-mail the Eligibility Policy Section and provide details of the agency's actions as well as any corrective measures taken. The Eligibility Policy Section will then answer the verbal or written complaint. If the Eligibility Program Administrator wishes to respond to a telephone complaint directly, the Eligibility Policy Section will notify the complainant to expect a telephone call from the Eligibility Program Administrator or designee within a pre-determined time period.
Complaints filed through the above system shall not include complaints alleging discrimination. Refer to 1530 for discussion of Civil Rights complaints. This system shall also not include complaints that should be pursued through the fair hearing process.
01530 Civil Rights Complaints -
1530 Civil Rights Complaints - Kansas shall maintain a system to ensure that no person in Kansas shall, on the grounds of race, color, national origin, gender, age, sex, disability, political belief, religion, sexual orientation, marital or family status, be excluded from participation in, or be denied the benefits of any Family Medical Program or be otherwise subjected to discrimination. This applies to all Family Medical programs.
1530.01 - Public Notification, Data Collection, Maintenance, Reporting, and Training
(1) - All applicants and participants shall be informed of the following:
(a) Rights and responsibilities;
(b) KDHE’s policy of nondiscrimination;
(c) Procedures for filing a complaint; and
(d) Procedures for filing for a fair hearing.
(2) – Regarding race and identity questions on the application, the applicant is encouraged to complete all questions regarding race or identity on the application. The applicant shall be informed that the information will be used for statistical purposes and will have no effect on his/her eligibility. However, if the applicant fails to provide this information, it is acceptable for the staff person to complete the questions by observation.
(3) KDHE, either directly or through contacted services, will provide bilingual services as needed.
(4) Local service centers, including contractors, shall complete and mail the Civil Rights Complaint Form, KC-6501, to KDHE Policy according to the procedures of this section.
(5) Local service centers, including contractors, shall cooperate with Personnel Services in the investigation and resolution of the complaint;
(6) Local service centers, including contractors, shall take any corrective action indicated by the investigation; and
(7) Local service centers, including contractors, are to insure that medical assistance staff receive training on the civil rights of applicants/recipients as well as procedures for handling civil rights complaints on a regular basis. This includes staff who answer the phones and staff who deal with the public in reception areas.
1530.02 Civil Rights Complaint Processing System – Discrimination Complaints or Allegations - Upon receiving an oral or written complaint alleging discrimination or other civil rights issue, the entity receiving the complaint shall:
(1) Log the complaint on the KC-6501, provide a clear summary of the complaint.
(2) Send a copy of the KC-6501 to KDHE Eligibility Policy. Retain the original in the case file. The referral must be made within 2 days of the complaint.
(3) KDHE Policy will consult with KDHE Legal, Personnel Services, and, if necessary, Senior Leadership to determine corrective action.
(4) KDHE Policy will communicate the recommended corrective action approach to the entity receiving the complaint.
(5) The local entity is responsible for carrying out the corrective action. This may include oral or written explanation, interview, change in agency action, or assisting the complainant to either file for a fair hearing, or another action.
(6) If the complaint cannot be settled within 10 days to the satisfaction of the complainant, inform the complainants that the issued will referred for additional consideration.
(7) Local staff shall contact KDHE Policy for additional remedies. These may include contacting HHS, consultation with KDHE Legal or other agency division to resolve the complaint.
(8) As part of the corrective action, contact with Personnel Services may be necessary.
(9) Staff must cooperate with Personnel Services in investigation and resolution of the complaint, to include taking the necessary actions indicated by the investigation.
(10) Retain a copy of the completed form KC-6501 in the case file.
01600 General Information about Other Programs and Miscellaneous -
1601 Case Records - Case records are required for all assistance cases and are to be separate from social service records. The eligibility record shall include required forms to establish eligibility for assistance and additional information and decisions reached regarding eligibility, the type of assistance, notices to the client, and authorization forms.
The case record includes all information about all individuals on a case. The case record is comprised of three (3) main components: 1) All information input into KEES, 2) The eligibility record held on KEES, and 3) information and documentation in the case file.
The eligibility record is the output of KEES which is transferred to the MMIS for claims payment and MCO assignment. All data input is a part of the eligibility and case record.
The case file is the collection of documents that support the information contained in the state eligibility system as well as all other documentation that relates to the case. Any information received, in any format, in relation to a case must be in the case file. The case file contains all documentation supporting the case processing activities, such as application forms, income verification and worksheets, correspondence, legal documents, requests for case maintenance, a log of case actions and customer contacts, and previous eligibility information for the household.
1601.01 Correspondence - Notices affecting the eligibility shall become a permanent part of the agency's record. Notices sent through KEES are maintained in KEES. Off-system notices are imaged to the case file.
(1) - Content of Notices - All notices should contain sufficient information to make clear their purpose, the information desired, and how the information is to be used. The wording should be clear, direct, and adequate to cover the subject. Care should be taken to avoid misunderstanding or misinterpretation.
(2) - Filing - Letters from clients are to be retained if they contain significant material.
(3) - Letters, newspaper clippings, and other material, should be dated and properly identified.
1602 Disposition of Obsolete Case Record Material - Destroy any material which is older than 36 months and is not currently in effect on active cases with the following exceptions:
(1) - The last application which opened the case;
(2) - For AABD cases converted to SSI (whether open for medical or not), the application and budget in effect for December 1973 must be retained indefinitely;
(3) - Retain indefinitely all documentation needed to establish current eligibility such as income verification, tax filing status, etc.;
(4) - Retain indefinitely a copy of the individual's Social Security card when it has been provided. In addition, the PA-3120.4 (Welfare Enumeration) form and copies of all documents used for enumeration purposes shall also be maintained indefinitely;
(5) - Retain indefinitely all material pertaining to unrecovered overpayments, including all documentation for the amount and cause of the overpayment;
(6) - Retain indefinitely all material pertaining to verification of the immigration status of aliens;
(7) - Retain indefinitely all materials pertaining to documentation of common-law marriages or paternity;
(8) - Retain indefinitely all documents used to verify citizenship and identity of the individual, including the ES-3850.
1602.01 Disposition of Closed Cases - Closed medical cases may be destroyed after they have been closed for 36 months except for (1) all material pertaining to unrecovered overpayments, or (2) cases that have a designated period of ineligibility which exceeds the retention period (e.g., first time conviction of fraud, etc.)
1603 Voter Registration - The National Voter Registration Act of 1995 requires voter registration to be available in public assistance offices. The Act also requires that anyone applying for or receiving public assistance, including Medicaid, be offered the opportunity to register to vote at the time of initial application, each eligibility review, and each report of a change of address. Each individual must be informed of this registration service and offered assistance in completing the voter registration form or declining the registration activity. The KC1100, Medical Assistance Application for Families with Children and the KC1500, Medical Assistance Application for the Elderly and Persons with Disabilities offers everyone the opportunity to register to vote or to decline to register. Completion of the voter registration question is not a condition of eligibility for assistance. If an individual does not complete this section of the application, it is considered an indication of voter registration. An answer of “Yes”, “No” or blank in the Voter Registration section has no bearing on case processing or eligibility. Those applying on-line are offered the opportunity to link to the Secretary of State's voter registration site. All those who answer "yes" are to be handed or mailed a voter registration application. Voter Registration forms can be returned to KanCare and will be sent to the corresponding Secretary of State’s Office within five (5) days of receipt.
1604 Estate Recovery - The estate recovery program has been established as a means to recover medical care costs from the estates and property of certain medical assistance recipients. See MKEESM 1725
1700 Delivery of Medical Cards - All medical cards are issued by the assigned Managed Care Organization (MCO). For individuals not enrolled in managed care, the medical care is issued by the Fiscal Agent. Cards are delivered by mail to the address of the Primary Applicant unless otherwise requested. If the individual requests a different mode of delivery, the agency shall consider the appropriateness of the request. When deemed appropriate the agency may use other modes of delivery including P.O. Boxes, General Deliveries, addresses of friends or relatives, or the address of the agency when it is necessary to hand deliver the medical card to the client, particularly for situations involving a homeless client.